With passage of the Accountable Care Act, the federal government has increased efforts to ensure accurate payments and to recover overpayments. Risk Adjustment Data Validation (RADV) audits are done by CMS and also the OIG to determine whether HCCS generated by the diagnosis codes submitted by PACE and Medicare Advantage organizations can be validated in medical record documentation. Diagnoses that cannot be validated contribute to a payment error rate. Our ValiDx service mimics CMS’s methodology and provides clients with a realistic view of their compliance level in regard to documentation, coding, and data submission.
The process is straight-forward and can be set-up as a single audit or annually. Once we obtain the necessary data files, our software generates the sample for auditing using the three-tier method CMS uses. We provide a complete list of HCCs to be validated with worksheets and dates of service to facilitate the collection of the medical records. Clients may electronically submit up to five supporting medical records for each CMS-HCC being validated.
The record review is done by Capstone coders and recorded in Capstone’s database, with each diagnosis being designated as submitted/valid, submitted/invalid, or not submitted/valid. Capstone will calculate the payment error based on the validation results. The extrapolated payment error estimate will be calculated according to published methodology.
Capstone will provide the following reports within 90 days of receiving all records:
- Report of all reviews and outcomes of all diagnoses audited, including diagnoses that need to be submitted or redacted.
- Payment error estimate and extrapolated payment recovery estimate
- Recommendations for further actions.
Mock RADV audits are priced based on program census, which determines the sample of records selected for review.