RISE Radio

Episode 26: What to know about the new era of RADV audits

• Ilene MacDonald

Share episode

Medicare Advantage plans are about to face unprecedented scrutiny as the Centers for Medicare & Medicaid Services (CMS) implements a dramatically expanded approach to RADV audits. Starting in 2025, every Medicare Advantage plan will be subject to contract-level RADV audits—a significant departure from the historical approach of randomly selecting 60 plans annually.
 
During this 17-minute podcast, Deborah Curry, risk adjustment programs director at Medical Mutual. breaks down the critical changes that compliance teams need to prepare for immediately. She offers practical strategies for surviving this new audit environment, emphasizing the importance of designated backup personnel, weekly progress huddles, and careful oversight of vendors retrieving medical records. 

Whether you're already facing a RADV audit or preparing for the inevitable, this episode provides essential guidance for navigating CMS' aggressive new approach. For deeper insights, join RISE in Tampa, Fla. on October 21-23 for the 26th Risk Adjustment Forum, where Curry will be sharing additional strategies for RADV readiness.

About Deborah Curry

Deborah Curry, risk adjustment programs director, Medical Mutual, joined Paramount Healthcare in May 2013 and oversees the Risk Adjustment, Coordination of Benefits, and Subrogation departments. Prior to her position with Paramount, she had 21 years’ experience working with the State of Ohio workers’ compensation program, both for the government and a contracted managed care organization. She came to Paramount with extensive knowledge in medical coding, provider billing and education, Medicare payment methodologies, quality assurance, and regulatory compliance.

Curry attended The University of Toledo for both her undergraduate and graduate degrees and currently holds a Master of Business Administration with major in Healthcare Systems Management. She is an active member of the American Health Information Management Association (AHIMA) and is a Registered Health Information Administrator (RHIA) and Certified Coding Specialist, physician based (CCS-P).Curry is also an active member of the America Academy of Professional Coders (AAPC) and is a Certified Risk Adjustment Coder (CRC). She holds certificates as a Risk Adjustment Practitioner (RAP) and Advanced HCC Auditor (AHCCA and serves as a Board Member of the University of Toledo Health Information Administration Advisory Board, Health and Human Services Alumni Affiliate at The University of Toledo, and Health Information Technology Advisory Committee at Owens Community College.

About the Risk Adjustment Forum

RISE’s Risk Adjustment Forum is designed for leaders in risk adjustment, coding, compliance, finance, and analytics across Medicare Advantage, Medicaid, Affordable Care Act, and commercial plans. 

The three-day event, which will take place Oct. 21-23 at the Grand Hyatt Tampa Bay, will tackle RADV audit ramp‑up and extrapolation, the Big Beautiful Bill Act, V28/RxHCC shifts, internal audit design, and CDI. 

 

 

Ilene MacDonald:

Hello and welcome to the latest episode of RISE Radio. I'm your host, Ilene MacDonald, the Editorial Director at RISE. Today we will be exploring CMS' new approach to RADV audits and how to prepare for them. To explain the ins and outs of RADV audits and CMS' new strategy, my guest today is Deborah Curry, Risk Adjustment Programs Director at Medical Mutual. Deb will be speaking about ramping up for RADV audits at RISE's 26th Risk Adjustment Forum in October. Welcome, Deb. Thanks for joining me today. I'm wondering if we can maybe start with the basics. Can you talk about the purpose of a RADV audit as well as how CMS historically approached them?

Deb Curry:

Sure. So the purpose of the risk adjustment data validation audits, RADVs, is so that the government ensures the accuracy of the data that is being submitted to them. So Medicare Advantage plans, our claims data and counter data goes to the government and so that data is used when we get paid. So they take into consideration the member's demographic, the member's chronic condition, some acute conditions as well, but the diagnosis codes, those are important and so when that data is submitted to CMS, either via claim submission directly you know what the provider bills or any supplemental submissions that we may send from retrospective chart reviews or concurrent chart reviews, or prospective chart or prospective chart audits, so that data that is being sent, we are required to ensure the accuracy of it.

Deb Curry:

CMS will then come back and audit to ensure that when we attested to that data we were true when we said yes, it's accurate, and it's just ensuring that because the government and our tax dollars pay for, you know, the Medicare program. The government is trying to be good, fiscally responsible with the monies that they're paying to the Medicare Advantage plans.

Ilene MacDonald:

In May, CMS and Dr. Oz announced an aggressive strategy to catch up and accelerate these enhanced Medicare Advantage audits and I wonder could you explain to our listeners the changes to RADV in 2025?

Deb Curry:

Sure, so historically and I apologize, you did ask me that. Historically, CMS has selected randomly Medicare Advantage plans, and so it used to be 30, and then they ramped it up a few years ago to 60. Now they're saying every Medicare Advantage plan as of 2025 is going to be selected for a contract RADV. And the difference between a contract level RADV and like a Part C improper payment measure, or formerly known as national RADVs, is these RADVs specifically target a plan and if there are any error findings then there could be monetary penalties.

Deb Curry:

Historically, prior to payment year 2018, so dates of service 2017, CMS the rule came out that they're not going to extrapolate any error payments. However, beginning with payment year 2018, which plans just finished that earlier this year, any error, any error rate, we will not get the you know fee for service error rate exception. They're going to extrapolate monies, which means that if there's an error rate found, they're going to take that error rate, not just against that member that maybe we didn't, you know, validate, but they're going to take it off the entire sampled population. So that's a big deal for health plans, the fact that they're getting more health plans, every health plan, and they're going to get aggressive about it. So we're assuming that we're going to get them back to back.

Deb Curry:

Historically, you've had a year, you know maybe two years in between RADVs payment

Deb Curry:

year, RADVs. However, now they're saying they're getting aggressive. They're hiring more coders, they're doing more plans and they're going to get aggressive with their schedule. So we're very it's like kind of buckle up and hold on. It's going to get bumpy.

Ilene MacDonald:

So if I'm a plan right now, what can I expect? Do you have any idea of what plans are looking at? As far as how much notice? I mean, I think I remember Dr Oz saying that they were going to hire all these coders by September 1st. It's unclear whether that has happened, but have you heard about any audits starting and what those are involving?

Deb Curry:

Yes, the first payment year, which is payment year 2019, 2018 dates of service that started we are in the middle of. Three of our Medicare contracts have been selected. So you know, you get the notice. And what has changed the most significant change it's really to before, prior to this particular new audit we had, we were able to have like 22 weeks. They've reduced that down to 12 weeks.

Deb Curry:

So the amount of time that we have to submit data to the government has been reduced as well, as we used to be able to submit up to five medical records per HCC, per diagnosis category. However, now it's only two. So they've shortened the timeframe and they've reduced the number of records we can submit per HCC. So in doing that, that's helping them be aggressive on their end, but it's putting a little bit of a burden on the health plan because we have to go pay for the medical records, get them sooner. You know the burden on the providers because now instead of just randomly selected health plans asking for medical records, y ou have every health plan asking. Also the third-party release of medical records they had to increase their rates because they are getting behind in their work and they weren't prepared for the influx as well. So it's hurting us financially, it's hurting us with time frames, and the ACA. We're in the middle of that

Deb Curry:

annual ACA, we're as well. So a plan has to be prepared and you kind of have to understand how we're going to divide and conquer because you can't tell them. Oh, I'm sorry, this is just too much. The government won't accept that as a hardship.

Ilene MacDonald:

Yeah, absolutely. And before we talk about, maybe, some strategies for prep, I'm wondering about the big thing that CMS was going to do extrapolation for plan year 2018. So can you talk a little bit about that and what the potential impact is for plans? So if this wasn't a burden enough, financially, what are we facing?

Deb Curry:

So what they used to do is they would take an error rate per member. So let's say a certain condition wasn't validated, right, and it would only be so if that individual member say they should have gotten $500 in risk adjustment payments and they ended up getting $1,000, well, that difference, right? That $500 difference would be on a member level basis. Now what they're going to do is say, okay, that member had diabetes and her error rate or his error rate was 10 percent at $500. Now all members that have you know in that sample population that the error rate for diabetes didn't pass, they're going to say, oh, that's $500 times 35 members, right? So they're going to extrapolate it off the entire population.

Deb Curry:

It's a very simplistic way to look at it. But instead of a $500 penalty, potentially you're looking at a $17,000 penalty, right? And then when you compound that over all the different errors, they're going to find that increases the amount of money that you're going to pay. Right? And extrapolation is something that and this is very peculiar in the rule, because they say they could extrapolate if there was significant error, and you know so actuarials across the board they do give you an algorithm within you know the RADV guidelines to kind of explain that extrapolation a little bit. So that is kind of nice of them, but the monetary penalties are just going to compound versus. You know the simple math.

Ilene MacDonald:

Yes, all right. So now let's talk about some ideas for plans to prepare for all of this. Do you have any suggestions that you're personally doing or that you recommend that others consider this year?

Deb Curry:

I think there's two different types of strategies. Ilene, I think you have to. So, all right, you've been selected. Now what do you do? Right? I think that what you need to do is you need to have a plan, you need to prepare for that plan and then have backups in the event somebody leaves. For instance, when they ask you who do you want to have their CDAT, which is their submission platform access, I say you put as many people as you can. You know if three people are going to take the lead, have a backup for that lead, because if something were to happen, you only have 12 weeks to submit that record. You know, you don't know, somebody could get hurt. You know somebody could resign, you just don't know. So always have a backup when you know, when you're signing up, who's going to have access to submit the records to CMS.

Deb Curry:

Make sure we do weekly huddles right, so we want to know where we're at, what problems are we having. And in those huddles I involve my leads over the audit. I involve our retrieval specialist as well as our submissions. I don't know what his name is, but he does our submissions and then submits our encounters, because then you know when we want to find a specific diagnosis. I'm going to go to him and say, all right, we've exhausted all measures. Is this the only claim I have that was submitted to CMS? With this you know diagnosis and if not, we're going to look for all the different claims. You know preparing a good chase list is crucial. So you have to know you have to be very targeted in the medical records you're going after. So you need to know the claim that was submitted and that's working with your claims team, submissions team, whomever that is. You need to know the diagnosis that was on the claim and the provider that billed it, because you're going to go directly to that provider or the third-party release vendor, whomever and you're going to request that medical so that you can submit it as soon as possible. When you get down to where we're at now, we've got three weeks left. We call it the nitty-gritty. This is where you're exhausting all efforts. You're relooking at the data, you're reconciling what you submitted into CDAT and making sure that that is accurate. You're updating your C-suite so they're aware, and then you have to do finance. You know they want their piece of the pie as well. How is this going to impact them? What should we accrue for what should we reserve? You know what monies do we need to hold back? In any event, there are any type of civil monetary penalties.

Deb Curry:

One of the things I would highly recommend you avoid is, or are cautious of, is what you put in writing, right, so I never say these are going to pass, these diagnoses are going to fail. It's always likely, possible, unlikely, because anything I do is discoverable. If I were to get you know an audit from CMS, you know a plan audit, right, and so I don't want to put something in writing and they're like wait, what did you do? Why did you think this? So be very careful how you report and what you're putting in those reports to the C-suite. A lot of it should be verbal, you know, because you don't want to say, well, we did this, this and this, and you know this is what CMS is going to do. I think, on those long-term strategies, okay, I think you want to prepare now, right, your team.

Deb Curry:

You should always, when you're reviewing medical records for any type of prospective review, retrospective review, concurrent, anything that you're doing, any you know, initiatives or strategies that you're doing you always have to take into mind is, if this medical record was being audited. What is it the best right? So we look at the medical records and ensure the accuracy. We're looking both ways. We're adding, we're deleting. We're not just adding diagnosis, we're looking at the validity of the diagnosis and I think that is key. Every plan if you're not looking both ways.

Deb Curry:

That is something we have to do in this new age, with CMS being aggressive and we can't overcode. We have to code to the official coding guidelines and not try to skirt the system or look at something. I mean there's gray in coding and I understand that. I've been coding for 30 years and so I understand that. But coding is coding right. There's no risk adjustment. Coding versus you, no, versus you know, hospital coding it's, there's coding, and we have to follow the Coding Clinics and the Official Coding Guidelines. And we have to do it right Because in the end you know the member's going to suffer and we have to be focused on our members. Member-centric is what we're here and why we do what we do in risk adjustment Because if I get the accurate monies from the government that we're entitled to and I'm not getting any penalties because we did do everything the way we were supposed to, then the member we can offer them lower premiums, more robust supplemental benefits.

Ilene MacDonald:

That's good advice and I know you mentioned one pitfall and sort of not putting it in writing and being very careful. Are there any other problem areas that you would suggest plans avoid or anything else that comes to mind?

Deb Curry:

I guess it depends on how much control you want when the amount of time has been reduced and if you're using a vendor to retrieve your records. You almost need to be more aggressive with your vendor, I think, because you can't rely on them saying they're going to get the data, because at the end of the day, you, as the health plan, are held responsible to getting that information. So if you have to have a weekly meeting with your vendor, if you need to have a meeting every two weeks, I think the vendor partner oversight has to be a little bit more robust during an audit. If indeed you're using vendors to help you retrieve your medical records, if you're doing it internally, I think that you have to stay on task and stay you know, make sure that there's tracking, appropriate tracking, accurate tracking, and you have to know, you know where you're at, Like, what have you requested, how have you requested it. So make sure we use Excel spreadsheets to do that, where we're tracking, and you just have to have a method so that you know what's coming in and what you're waiting on with the. You know when, what you've submitted to the government, what you, what medical records you've requested, and so I think that is huge and I and I can't stress this enough Don't panic, I know there's a lot going on and we're all in this together.

Deb Curry:

So find your peers. I get emails and RISE is wonderful at helping me find peers. I've been a part of the RISE, attending RISE, been a part of the speaker network, I guess, and have loved meeting my friends over the last almost 11 years. Reach out to them, Ask them. I mean, we're all here to help each other. And so don't feel like you're on an island, Don't feel like you're doing this all alone.

Ilene MacDonald:

Thank you, Deb. I really appreciate your time today. And, Deb, you'll be talking in depth about RADV audits at the Risk Adjustment Forum and hopefully seeing your peers there and your speaker friends. For those listeners who are interested, the Risk Adjustment Forum will take place October 21st to 23rd in Tampa, Florida. I'll put a link and details about the conference in the show notes. And, Deb, thank you again. This was great.