RADV Audit White Paper – Top 5 Takeaways

RADV Audit White Paper – Planning Ahead For Strict HCC Compliance Protocols

Key Findings on  From 400 RADV Audits, 2011-2021 


What is a RADV Audit?

The Medicare Risk Adjustment Validation Program (RADV Audit) was created to identify and correct past improper payments to Medicare providers and implement procedures to help the Centers for Medicare & Medicaid Services (CMS), Medicare carriers, fiscal intermediaries, and Medicare Administrative Contractors (MACs) implement actions that will prevent future improper payments.


Simply put, it is a process whereby CMS validates payments and recoups over-payments.


How does a RADV Audit work?

CMS selects a statistically valid sample of members enrolled in an Affordable Care Act (ACA) compliant plan. Providers whose patients are selected for an audit receive requests and must provide copies of medical records.The audit seeks to verify that diagnosis codes, submitted on claims and reported to CMS, are accurate, properly documented, and coded with appropriate levels of specificity.

In accordance with the provisions of the Patient Protection and Affordable Care Act (PPACA) and its risk adjustment data validation standards, CMS then takes that statistical information and extrapolates from it the amount of overpayment that the health plan or billing entity is responsible for. In many cases this can range from several $100Ks to several $MMs.

HCC Compliance RADV Audit

Takeaway 1: Small errors return large chargebacks

Extrapolating from statistics based on errors yields significant sums.


In the three case studies referenced in the white paper, the overpayment ranged from 10% – 12% of total annual revenue. As a percentage of profit, that is a sizable number. While Einstein may have said that compound interest is the most powerful force on earth, we say that extrapolated overpayments are the most powerful force in ruining your year.


Takeaway 2: Some codes get misused more than others


These are the top three misused HCC codes from the audits data:


HCC Description HCCs added by unlinked chart reviews Estimated payments from unlinked chart reviews Percentage of unlinked payments
HCC108 Vascular Disease 105,607 $269,536,256 10%
HCC18 Diabetes w/ comp 74,221 $208,226,576 8%
HCC111 COPD 67,703 $189,101,725 7%


Takeaway 3: Provider behavior is the first thing to fix

While there are many ways to chase down diagnoses after the fact, the gold standard for HCC coding is at the point-of-care, right there with the patient. The opportunity for improvement in this stage has more to do with the tools that change behavior than the tools that chase data. Changing behavior is difficult, and the old-fashioned lecture approach to HCC learning is not likely to succeed.


Takeaway 4: Proper documentation fixes everything

Once the challenge of changing provider behavior has been tamed, the next beast lives inside the EMR. Whether you’re talking recapture rates or suspecting, there are significant financial risks in coding without proper documentation. Solutions that connect encounter data to HCC documentation to automate compliance are mission-critical for physician groups. These solutions will help groups provide top-quality care and protect them from negative RADV audits.


Takeaway 5: Without proper tools, documentation is daunting

At the risk of shameless self-promotion, we have enabled myriad providers with the tools to ensure the best possible outcome from a RADV audit. From capturing diagnoses at the point-of-care to ensuring documentation compliance — the DoctusTech family is ready for an audit. Our tools mean you are unlikely to be caught with your hand in the CMS cookie jar, and be put in the uncomfortable position of watching your revenue evaporate.


To learn more about how we prepare you for a RADV audit, help your providers improve HCC coding, and boost RAF accuracy by 30%, book some time with our HCC expert HERE.



Access the full white paper here

Planning Ahead For Strict HCC Compliance Protocols
Key Findings From 400 RADV Audits, 2011-2021

HCC Compliance RADV Audit White Paper

HCC Quick Start Guide


Leave a Reply

Your email address will not be published. Required fields are marked *