Risk Adjustment Data Validation (RADV) Audits

To be prepared for RADV, plans can employ the following if they do not currently have a compliance oversight process in place:

1. Review the CMS website for RADV here:
   Medicare Advantage Risk Adjustment Data Validation Program | CMSWhat is on this website?
   • Overview of the CMS RADV program
   • Error calculation methodology for different Payment Years, Questions and Answers about the audit reports
   • Audit Methods and Instructions for certain Payment Years
   • Questions and Answers about general questions and the MA RADV program

2. The Office of Inspector General (OIG) offers a toolkit that identifies high-risk Hierarchical Condition Categories (HCCs).
   
   Toolkit: To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services

   Why Use the Toolkit?

   • Pinpoint areas that may require additional attention
   • Support your efforts in ensuring that risk payments align with increased utilization and care delivery

   By integrating this toolkit into your audit preparation strategy, you can enhance your compliance and operational efficiency.

3. Have BluePeak perform a mock audit of your compliance oversight processes related to Risk Adjustment Data Validation
   Our Mock RADV Compliance Audits Include:
   • Evaluation of policies, procedures, and reports
   • Effectiveness review of plan processes supporting Encounter Data Processing System files
   • Chart review processes for deploying best practices
   • Review of provider engagement and communication procedures
   • Review of reporting processes, including auditing and monitoring for accuracy and inter-rater reliability

Note: BluePeak does not perform financial analyses or project risk adjustment impacts of potential audits.