The Risks

RADV (Risk Adjustment Data Validation) Audits

RADVs have been a concern for MA plans, but are anemic when compared to what is coming . . . . . soon.

CMS has now authorized RACs to takeover detailed auditing AND finding overpayments.  These private companies that are given access to the Medicare Data Bank and receive a percentage of repayments made to CMS.  They have been extremely successful in Medicare A & B.  In 2011, they begin work with Medicare Part C and D; Medicare Advantage and Prescription Drug Plans.  The RACs are aggressive.

The Impact.

The impact will not only affect MA plans, but will ultimately slide downhill to the provider level.  “Risk” contracts will have new risk, but, providers that help limit risk will be at a premium.

Our Experience.

Our experience is that most plans have a high percentage of overcoding:  20-40%.  The RACs will find your overcodes . . . and then some.  The task of responding to the RAC requests for records is daunting.  MARSI catalogs each defensible code we review and can produce a copy of “the best single record” that supports the assignment.  It is a highly valued service that is added at no additional cost.

We need to help you prepare for the inevitable.  The RACs can “look back” three years so it is important to start today!

Undercoding, Under Submissions, Under Reimbursement, Never Submitted

Historically, we have found significant increases in reimbursement for our clients even after reconciling over submission and our fees . . . from $100 - $300 PMPM.  But, this is not just “low hanging fruit” of “diagnosis last year, none this year” or medication cross walk.  This is an “eyes-on” review that finds conditions that should have been documented, coded and submitted.  This takes “reading between the lines.”  But it also highlights the knowledge deficits of each physician.

Our findings generate queries to the physicians that not only result in further submissions, but, also, reinforces MARSI physician training . . . chart-by-chart.

Our process identifies all of the possible ICD-9 Dx that should be or should have been submitted.  All of our clients have some codes that were never submitted, but should have been.  With one client that was 40% of all codes that were clearly documented and defensible.  Regardless, the “hidden” diagnoses and codes that should be submitted are not found without “eyes-on-the-chart” account for an average of twice as much as the codes already submitted. 

For an explanation of “why?”,  please see Problems and Challenges.