CRC Compliance and RADV Audits 2

Question 1

During a RADV audit, an auditor reviews HCC 18 based on code E11.22. The chart shows 'diabetes with renal manifestations' but no mention of CKD. What is the likely outcome?

Accepted Answer

HCC will be confirmed because diabetes with renal manifestations supports E11.22

Answer

HCC will be deleted due to insufficient specificity

Answer

HCC will be downgraded to HCC 19

Answer

The audit will defer to the submitting organization

Question 2

An MA plan discovers systematic upcoding of diabetes by a provider group. Under the False Claims Act, what element must be present for liability?

Accepted Answer

Knowledge of false claims or deliberate ignorance of their falsity

Answer

Proof the plan directly instructed providers to upcode

Answer

Evidence of actual financial harm to CMS

Answer

Demonstration that every single claim was intentionally fraudulent

Question 3

Which documentation practice presents the highest RADV audit risk?

Accepted Answer

Submitting diagnosis codes from problem lists not addressed in encounter notes

Answer

Templated notes with comprehensive review of systems

Answer

Multiple providers documenting the same condition differently

Answer

Addendum notes added within 24 hours

Question 4

What is the primary purpose of the RADV Fee-for-Service Adjuster?

Accepted Answer

To account for coding errors in the FFS benchmark that inflate the comparison baseline

Answer

To increase payment recovery amounts

Answer

To penalize plans with high error rates

Answer

To adjust for regional coding variation

Question 5

A compliance officer identifies suspiciously high HCC 96 capture rates for a provider group. What is the appropriate first step?

Accepted Answer

Conduct a targeted chart audit of a sample of HCC 96 claims

Answer

Immediately report to CMS

Answer

Terminate the provider contract

Answer

Apply a correction factor to future submissions

Question 6

Which encounter type is NOT acceptable for risk adjustment diagnosis submission?

Accepted Answer

Lab-only encounter with no face-to-face provider interaction

Answer

Office visit with a physician

Answer

Telehealth visit with audio and video

Answer

Home health encounter with a qualified provider