RADV is one of the most important aspects of medical coding. RADV or risk adjustment data validation deals with the risk adjustment scheme introduced by the HHS (U.S. Department of Health and Human Services) for keeping insurance premiums stable in the wake of the health insurance reforms that will come into effect in 2014 as part of the Affordable Care Act (ACA). The ACA basically serves to provide access to quality and affordable health coverage to all.
More about Risk Adjustment
Risk adjustment ensures that insurers who are enrolling individuals healthier than average will pay insurers who enroll individuals sicker than average in their state. This will ensure that the revenue of insurers will be similar to the situation when they are allowed to incorporate health risk into their premium pricing calculations. According to the Congressional Budget Office these risk adjustment transfers are estimated to amount to around $10 billion each year.
RADV Audits
The CMS (Centers for Medicare & Medicaid Services) employs RADV audits for validating the accuracy of Hierarchical Condition Categories that have been submitted for payment by Medicare Advantage health plans. The validation takes place after the collection and submission of the data to the CMS, and the payment by the CMS to the MA health plan.
The RADV audits consist of National Audits and Targeted Audits. The National RADV Audit involves random sampling of Medicare Aid health plans while Targeted RADV Audit involves targeting specific health plans which must be audited. The CMS notifies the MA health plan of the audit and this notification contains MA contracts that must be audited, and members within each of the contracts and HCC diagnoses codes that need to be audited.
- The MA health plan must validate each HCC that has been reported to the CMS by the plan for the audited period. Healthcare providers who have provided treatment to anyone whose name is in the RADV audit must make available the relevant medical records.
- The RADV audit process involves securing IP/OP hospital as well as physician medical records for the members audited, review of the medical records, identifying the best medical record and submitting it to CMS.
- The RADV audit will be carried out in the calendar year following the collection and reporting of the HCC data, and after payment being made to the Medicare Aid health plan by CMS. The audit process needs to be completed in a twelve-week period.
A Medical Billing and Coding Company Can Help
An experienced medical coding company can handle these aspects effectively. It can offer affordable MRA/HCC coding with validation for RADV. Healthcare practices can fully focus their efforts on taking care of their patients well knowing that all their coding requirements will be comprehensively and flexibly handled.
An efficient medical coding company is updated on all the rules and regulations that keep changing. Efficient billing and coding are vital for the healthcare provider to get adequate payment for the services rendered, and the right medical billing and coding company can provide all kinds of billing and coding solutions including MRA/HCC coding with RADV validation.