Compliance & Regulatory Requirements Flashcards

What was the most significant policy change in the 2023 final RADV rule?

Answer: CMS confirmed authority to extrapolate audit findings from a sample to full contract enrollment

Extrapolation means errors in a sample of 200 charts could be projected to millions of members, dramatically increasing financial stakes.

Which OIG-recommended compliance element specifically addresses risk adjustment operational risks?

Answer: Specific policies for diagnosis submission accuracy, chart review vendor oversight, and overpayment identification

Risk adjustment requires specific policies addressing unique operational risks like diagnosis validation and vendor management.

Which OIG concern has been most consistently cited regarding MA risk adjustment?

Answer: Diagnoses submitted that are not supported by medical record documentation

OIG has consistently focused on unsupported diagnoses — conditions submitted where documentation does not adequately support the code.

When a CRC identifies a potential compliance issue during chart review, what is the appropriate escalation?

Answer: Document the finding and report through established compliance channels

Document specific details and report through compliance channels. Do not investigate independently or discuss with the provider.

How does the MA organization's 'attestation' requirement relate to risk adjustment compliance?

Answer: The organization must attest that submitted data is accurate, complete, and truthful, creating legal accountability

The attestation creates legal accountability. Submitting false certifications violates the False Claims Act.

What compliance challenge is unique to multi-state MA operations?

Answer: Varying state documentation standards, provider licensure requirements, and record retention laws create inconsistent practices

Multi-state operations face challenges from varying state-level requirements that affect documentation quality.