4 Biggest Takeaways from CMS’s RADV Audit Program Updates

ICYMI: RADV audits are undergoing a massive overhaul, and if your organization provides care to any Medicare Advantage members, here’s what you need to know.

Risk Adjustment Data Validation (RADV) audits are nothing new to healthcare organizations. Overseen by the Centers for Medicare & Medicaid Services (CMS), the purpose of RADV audits is to verify the accuracy of risk adjustment data and ensure that payments are supported by patients’ health documentation (cue the medical record audits!).

RADV audits have been administered by CMS since 2007 without any major revisions to the program. But a recent announcement from CMS means that is soon to change.

What Changes are CMS Making to RADV Audits?

CMS recently announced a significant ramp-up in both the pace and the scale of RADV audits. This means all eligible plans will now be audited, with records requested all the way back to performance year (PY) 2018. In other words, no plan will be left behind with the new influx of audits.

In prior years, only a small subset (around 60) Medicare Advantage plans were selected for RADV audits. This selective approach is now being retired, and instead, every eligible Medicare Advantage plan is now fair game for RADV audits—that’s over 500 plans! Think of it as a “no plan left behind” strategy, meaning the scale and scope of RADV audits is about to increase significantly.

4 Key Takeaways from CMS’s RADV Audit Program Changes

So, what do these new changes mean for you and your organization? Let’s take a look at the biggest takeaways from CMS’s announcement.

1. You need to know where your older records are—and retrieve them.

Because the lookback period now extends to PY 2018, HIM teams must be prepared to go beyond current systems and dig into off-site archives, legacy EHRs or other storage solutions. Records that once felt safely “in the past” are now necessary for compliance. Ensuring you can access older records will be a critical factor in audit readiness.

2. Bigger sample sizes means bigger stakes.

In the past, a RADV audit would only pull a small number of charts for review. Now that number has increased to up to 200 charts per plan.

But increasing chart volumes isn’t the only thing at stake. CMS can now also extrapolate the findings from that sample to your plan’s entire member population. What does this mean? A single set of coding errors could trigger significant financial implications for thousands of members—and for your organization.

3. All plans are now eligible for audits.

The combination of larger sample sizes and the massive increase in the number of plans audited is what makes this change so daunting for Medicare Advantage organizations. Previously, CMS only audited about 60 plans per year, but now it’s auditing all eligible plans (around 550).

4. Documentation requirements are getting stricter.

When CMS requests records, they expect every page, every signature, and every piece of supporting documentation—no exceptions. The days of citing an “unretrievable” record as a defense are over. That makes robust retrieval processes and organized record management more important than ever.

3 Things You Can Do to Prepare Now

We get it, change is scary—and it usually means you have to scramble to prepare for the growing pains of following new rules, managing more requests and arming your team with what they need to succeed. But now that you know more about the future of RADV audits, here are some tips you can use to make sure you’re ready when the auditors come knocking on your door.

1. Proactively source and review archival medical records.

Start mapping out all your medical records, all the way back to 2018. This includes records that might be sitting in archived systems or even in off-site storage. By identifying potential gaps early, you’ll avoid scrambling when CMS comes calling. Think of it as creating a “radar map” of your data sources so nothing slips through the cracks. It’s also a good idea to test your access to those older repositories now so you’re not caught off-guard when a request deadline is looming.

2. Ensure your documentation is accurate.

With the increase in both charts and the number of plans being audited, it’s critical to ensure all of your documentation is correct and complete. One set of coding errors could trigger significant financial implications for thousands of members, so it’s essential that your records accurately reflect the services provided.

3. Make sure your team has the resources they need—or risk falling behind.

If your team currently handles RADV on their own, expect these changes to monopolize their time. With the number of charts per audit increasing by a whopping 550% and the number of plans being audited going from a few dozen to every eligible plan, you can expect the increase in workload to be significant.

If that all feels overwhelming (because it is!), a specialized release of information partner like HealthMark can streamline the process, completing audits on time and accurately without straining burdening your staff.

Final Thoughts

CMS’s RADV updates raise the stakes: all Medicare Advantage plans are now being audited, the lookback extends to PY 2018 and sample sizes have increased to from 30 to 200 charts, putting more work on the shoulders of HIM teams. And if that wasn’t enough, any miscoded records or mistakes within the audit could be extrapolated to your entire patient population.

Is your release of information process ready for this change? Now is the time to prepare for the new standards for completing RADV audits and partner with experts who can help you conquer your audits accurately and compliantly.

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