Retrospective Risk Adjustment

With CMS tightening risk adjustment payments to plans and now performing RADV Audits, what’s a reasonable approach to preparing for these audits while at the same time ensuring our Medicare Advantage Plan is receiving CMS payments?

Organizations with Medicare Advantage Plans have been informed that, for 2011, CMS will expand the Hierarchical Condition Categories (HCC) from the current 70 HCC groups to 87 groups. That being said, this will broaden possibilities for correct diagnosis code classification.

At AE & Associates, our Retrospective Chart Review includes all the processes needed to implement a successful retrospective service where the plan is reimbursed at a higher rate. Our services encompass the retrieval of medical records of members who are most likely to have incomplete, inaccurate, or missing codes, retrieving and scanning charts at the provider office, and preparing the data file for the health plan for submission to CMS.