It seems like Risk Adjustment for Medicare Advantage is ever-evolving. According to a Final Rule, published by CMS in the Federal Register on May 23, 2014, the one thing we can certainly expect more of is audits.
CMS will be introducing a Recovery Audit Contractor (RAC) for Part C, slated before the end of 2014. RAC auditors use a combination of methods, including medical record review and automated edits, to identify improper payments. Currently, there are RAC contractors in Part A, B and D--so the addition of a Part C RAC will mean that all of Medicare is under RAC audits.
We don't yet know what RAC audits for Part C will look like--but if you want to stay ahead of the curve, you should be looking at your data for any anomalies now. Speaking at an America's Health Insurance Plans conference, Sonja Brown, a health insurance specialist in the Center for Program Integrity in CMS’s Division of Plan Oversight and Accountability,initial areas of review are end-stage renal disease (ESRD), hospice and Medicare as Secondary Payer (MSP).
In addition to the RAC, beginning in 2015, the OIG will be doing their own Risk Adjustment Data Validation Audits (RADV), which we assume will look just like a CMS RADV, but may be more targeted.
This means that with so many audits going on simultaneously, it will be the rare medical group that is not affected. Medical groups should be doing their own internal chart reviews to determine where more physician education is needed.
We'll continue to keep you up to date on new and changing rules from CMS as we become aware of them.
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