Compliance and RADV Audits Flashcards
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Read the first 6 Compliance and RADV Audits flashcards as text
An automated coding system assigns HCC codes without provider documentation review. Which OIG compliance element has failed?
Answer: Internal monitoring and auditing
Internal monitoring and auditing failed because the organization did not detect the automated system was assigning codes without documentation verification.
A RADV auditor finds a provider note signed 90 days after the date of service. What is the impact?
Answer: Late signature creates a rebuttable presumption of invalidity
A significantly late signature raises credibility concerns. The burden shifts to the plan to demonstrate documentation reliability.
An MA plan discovers a closed provider group's records may be unavailable for a RADV audit. What is the plan's obligation?
Answer: Make good-faith efforts to obtain records and document those efforts
Plans must pursue all reasonable avenues to locate records from closed providers, documenting their efforts.
What is the significance of the 'one-best-code' methodology in RADV audits?
Answer: Auditors assign the single most accurate code, which may differ from what was submitted
RADV coders independently assign what they determine to be the most accurate code. If it differs from the submitted code and maps differently, the submitted HCC may be deleted.
An internal audit reveals a 15% HCC error rate in 200 charts. What is the most compliant course of action?
Answer: Extrapolate the error rate and report estimated overpayment to CMS within 60 days
Under the 60-Day Rule, the plan should extrapolate to the full population and report. Delaying violates the reporting obligation.
Which compliance safeguard is most critical when using chart review vendors for retrospective risk adjustment coding?
Answer: Prohibiting vendors from being compensated based on HCCs identified
Incentive-based compensation tied to HCC identification creates a financial incentive to overcode. CMS and OIG have specifically identified this as a risk.