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When CMS proposed expanding the risk adjustment audit program in 2015, it was looking to
cover all Medicare Advantage (MA) Plans, annually. CMS wanted one of two conditions:
1. Condition-Specific
2. Comprehensive Audits
CMS wanted one of the two implemented due to the fact that the powers at be then, strongly
believed that the diagnosis data was fraught with epic upcoding mistakes which were being
submitted by all the MA organizations. This was a concern for CMS as they were concerned
RAC intensity possible also on the heels of the big three fraud investigations this year
RAPS (Risk Adjustment Processing System) to EDPS (Encounter Data Processing
System)- as of 2020, MAPlans will be subject to 100% EDPS for records
(currently 25% of Risk Scores are based on EDPS/75% is RAPS)
different HCC coding models: CMS-HCCs and HHS-HCCs. Each model is designed to
capture population complexity and severity. To be more specific, the CMS/HCC model was
adapted into the HHS/HCC Model and is utilized within some of the Alternate Payment
National Sample which consists of a small group of MA Plan members and focus on
calculating error rates without identifying financial impact
Targeted Audits are broader and intensive in nature. They are made up of a random
sample from 201 MA Plan members. Targeted audits place the
burden of proof on the MA Plan, to produce a valid face to face
encounter for each date of service/claim submitted previously by
the MA Plan. Each medical record must be able validate each reported diagnosis that
correlates to an HCC/RXHCC submitted to CMS by the MA Plan.
HHS RADV
All MA Plans are required to annually participate in a Health Exchange or (HIX), RADV
audit. These audits are comprised of a 200 Plan member sample for
each MA Plan. HHS RADV Audits, also place the burden of proof on
the MAPlan, to produce a valid face to face encounter for each date of
record must be able validate each reported diagnosis that correlates to an HCC/RXHCC
submitted to HHS/CMS, by the MA Plan. The HIX HCC Program is designed based on
budget neutrality and the outcome will reflect MA Plan performance and overall drive the
Request for RADV audit worth $ 2000 + 30 minutes consultation worth $ 250
completely free
GET STARTED
Is the record for the correct calendar year for the payment year being audited?
Are there valid credentials and/or is there a valid physician specialty documented on the
record?
Certified Risk Adjustment Coders (CRC). They all will have to be focused on compliance
with any new requirements/ changes that may be implemented under a potential a MARA
Contracting Program. Additionally, I will venture to say that extrapolation, may well be
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