Audits / Reviews of Medicare Advantage Programs and Providers
CMS has a risk-adjusted payment methodology for Medicare Advantage programs . The methodology is based on diagnostic information as well as demographic information . In providing covered services to SCP enrollees , providers agree to comply with access and reporting requirements .
CMS conducts data validation every year after risk adjustment data are collected and submitted , and payments are made to Hometown Health . The purpose of the risk adjustment data validation is to ensure risk-adjusted payment integrity and accuracy . Risk Adjustment Data Validation ( RADV ) is the process of verifying that diagnosis codes submitted for payment by SCP are supported by medical record documentation for a member .
Overview of CMS Risk Adjustment Data Validation Audit CMS data validation is accomplished through medical record review . SCP requests the medical records from the provider and submits them to the designated CMS contractor for review . The goals of the data validation audit are to :
• Validate member diagnosis through documentation in the medical record
• Validate appropriate coding according to ICD-9 / 10 Guidelines
• Identify provider discrepancies in coding and documentation
• Measure accuracy of risk adjustment discrepancies
• Measure impact of SCP member payments
91