18 Aug 0
CMS notified all PACE Organizations (POs) and other risk-adjusted entities yesterday of their plans for RADV (Risk Adjustment Data Validation) audits for Payment Year 2012. Organizations will be notified on Sept 14 if selected for an audit. (If anyone wants to know details of the pain involved in a RADV audit, ask me…)
RADV audits are conducted to enforce compliance regarding the submission of complete and accurate diagnosis data in the Risk Adjustment Processing System (RAPS). Typically, incomplete or inaccurate RAPS data leads to overpayment to plans, but it can also cause underpayment.
POs must report and return overpayments (usually caused by incorrect or unsupported diagnosis codes in RAPS, but also related to PDE, DIR, LIS, EWWPS or other payments) as required by the Affordable Care Act. In a spirit of cooperation, CMS is allowing plans to redact incorrect information from 2011 Dates of Service prior to the audit, which greatly reduces the potential extrapolation costs of incorrect or unsupported diagnosis codes. In our work with many PACE plans, we know that mistakes happen and inaccurate and unsupported codes are submitted.
We have always advised plans to correct these errors, but the process for correction is not always easy or simple. It is a lot easier to commit errors in RAPS than to fix them. Please refer to the February 18, 2015 HPMS Memo, “Guidance for Reporting and Returning Medicare Advantage Organization and/or Sponsor Identified Overpayments to the Centers for Medicare & Medicaid Services (CMS)”, for overpayment operational guidance about how to remedy errors. POs must first obtain an overpayment remedy ticket number by calling the MAPD Help Desk, 1-800-927-8069 firstname.lastname@example.org at least 24 hours prior to the submission deadline.
CMS generally expects that an organization’s return of overpayments will be implemented by submitting corrected data. CMS’ systems will then recover the overpayment through routine payment systems’ schedules.
If you would like more information about how to be compliant with your data requirements or would like an assessment of your compliance status, please contact us.