December 16, 2024 in HLTHworks

RADV is launched. Are the health plans not selected learning from the selection criteria? 

On November 14, 2024, the Centers for Medicare & Medicaid Services (CMS) initiated Payment Year (PY) 2018 Risk Adjustment Data Validation (RADV) audits, notifying 60 Medicare Advantage (MA) contracts of their selection. These audits are critical for ensuring the accuracy of risk-adjusted payments by verifying that diagnoses submitted by MA organizations align with medical record documentation. But did you know why there are extra health plans being audit, CMS is taking a special interest into diagnoses not linked claims. Thus, CMS is review more retrospective supplemental findings and, of course, in-home assessments. CMS is testing the validity of these two initiatives. Are you? 

Navigating the complexities of RADV audits demands meticulous attention to detail and a thorough understanding of CMS guidelines. At HLTHWorks, we empower health plans with the expertise, tools, and services needed to confidently manage these audits and ensure compliance, plus quantify each strategies value.

How HLTHWorks Can Support Your Audit Needs

  • Coding Services (first and second pass): Our certified coding professionals accurately capture and validate diagnoses to ensure compliance with CMS standards, minimizing risks during audits.
  • Up and Downside Medical Record Reviews: We provide in-depth reviews of medical records to verify that all documented diagnoses are fully supported, helping to reduce the potential for overpayments or underpayments.
  • Audit Preparation and Support: From initial preparation to post-audit analysis, HLTHWorks delivers end-to-end support, ensuring your organization is fully prepared and compliant throughout the RADV process.
  • Test strategic impact of:
    • In-home assessments
    • Medical record reviews 
    • Concurrent coding pre and post coding 
    • Billing completeness
    • Reconciliation to return files

By partnering with HLTHWorks, health plans can streamline the RADV audit process, safeguarding financial accuracy and compliance, plus foresee any future regulation impact.

Beyond Audits: Partnering with HLTHWorks for Success in a Complex Regulatory Landscape

In today’s ever-changing regulatory environment, health plans need a strategic partner with deep expertise in government program compliance and performance optimization. At HLTHWorks, we go beyond audits to help you:

  • Expand operations strategically
  • Optimize performance and improve outcomes
  • Reorganize departments for role clarity and efficiency
  • Launch new services or investments with confidence
  • Tackle compliance challenges effectively
  • Explore and execute future market strategies

Whether you’re managing a Medicare Advantage (MA) plan, Affordable Care Act (ACA) offerings, Medicaid programs or serving as a vendor, HLTHWorks offers the insight and guidance you need to thrive.

Stay Ahead with HLTHWorks Regulatory Insights

Our subscription service keeps your team informed by analyzing HPMS and regulatory memos, providing timely updates to ensure compliance and support decision-making. With our expertise, you can anticipate regulatory changes, seize growth opportunities, and maintain the highest standards of care and accountability.

Your Partner in Excellence

At HLTHWorks, we understand the challenges and opportunities in today’s healthcare landscape. By working with us, health plans can confidently navigate RADV audits and regulatory requirements while focusing on delivering exceptional care and achieving long-term growth.

Contact HLTHWorks today to learn how we can support your organization’s success.



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