by RISE
19. July 2010 17:57
CMS has stated that they plan to audit 110 MA plans total during the two year period of 2010-2011. This is almost 3 and ½ times the amount of plans CMS selected in 2009 for the 2007 targeted RADV audit. The chances are good that your health plan will be selected. The lucky plans selected will have 12 weeks to request, review, select and submit the one best medical record to substantiate each HCC. CMS typically chooses 201 members with anywhere from 400 to 700 HCCs for validation.
If your plan is notified tomorrow of its selection, would you be prepared? Here are a few ideas we had in advance of our RADV audit as well as some lessons learned while going through the audit.
Conduct a mock audit - select 67 members with high risk scores, 67 members with moderate risk scores, and 67 members with low risk scores (this is how CMS did it for the 2007 targeted RADV)
Request every single record from every provider the member has seen. Don’t assume that the first record you receive is the best record. You may find that another record captures the same HCC as well as an additional HCC that you never reported.
Start verifying/cleaning your providers’ addresses and phone numbers now!
Decide whether you have enough internal resources to handle the audit or whether you will need to outsource.
Have multiple certified coders review each "best medical record" for consistency.
Put your plans on paper – develop a work plan so you will know exactly what to do when the notification of selection is received.
I could go on and on about this topic, but I hope this provides enough information to get you started. Don’t delay. Start preparing today for the RADV audit. It is inevitable – ALL plans will be selected at some point.
Lesley Weir, Director of Risk Adjustment, VIVA Health
