EXL Health RADV Mock Audit

Medicare Advantage (MA) plans are facing stricter regulations to determine overpayments within risk adjustment data validation (RADV) and improper payment audits by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), causing increased risk exposure and revenue concerns. Issued by CMS in early 2023, the ruling includes capitation rates, model restructuring to address ICD-10-CM, the implementation of a contract level error rate, and extrapolated recoveries starting with the 2018 plan year. CMS projects overpayments of $479 million per audit year, averaging to $4.7 billion between 2023 and 2033i. In the ruling, CMS also excluded the fee-for-service (FFS) adjuster that allows for permissible threshold errors, a factor that would have significantly reduced penalty amounts.

The intent of these changes is to mitigate overpayments, protect taxpayer dollars, and ensure plans adhere to high standards of accountability and accuracy within the payment system. These CMS’s refined audit standards can cause substantial reputation and financial consequences for MA plans, and requires transformative approaches to monitor and work to eliminate reporting of unsupported conditions.

Reduce risk and maintain compliance

While RADV and OIG audits are here to stay, payers and at-risk providers should take proactive action to assess risk and implement corrective action, policies, and procedures.

At EXL Health, our RADV Mock Audit solution supplies insight on the accuracy of your program. Even better, based on the results and our client’s needs, we work as collaborative partners to help resolve process and procedure gaps to limit future risk exposure and help clients achieve long-standing success in the evolution of risk adjustment.

AI and advanced analytics for quality, accuracy, and scalability

Leveraging innovative AI-enabled solutions and expert coder validation, we help our clients assess the accuracy of their coding results and predict potential unfavorable compliance and financial impacts due to inaccuracies.

Going beyond fragmented solutions that only identify conditions, our end-to-end solution delivers actionable data-driven results.

In working together, our approach will help you:

  • Ensure accurate risk adjustment data and compliance with RADV requirements
  • Optimize reimbursement by identifying coding and documentation inaccuracies
  • Incorporate subject matter expert review on missed or erroneously added conditions
  • Enable data-driven decisions through comprehensive reports
  • Drive process and mitigation efforts through insights and targeted training
  • Provide actionable results for clients to incorporate into prospective work, provider onboarding, and training to ensure sustainable regulatory compliance.

Going beyond fragmented solutions that only identify conditions, our end-to-end solution delivers actionable data-driven results. This includes error rates extrapolated to calculate the full risk exposure, deep root cause analyses to show risky trends and patterns within provider groups, and reporting high failure rated conditions. Together, we will develop and execute a data-led action plan to scale and limit the laborious audit approaches of yesterday, resulting in potentially savings clients hundreds of thousands to millions of dollars from eliminating wasted operations and penalties.

I: Federal Register, Vol. 88, No. 21, Rules and Regulations 2023-01942.pdf (govinfo.gov)