MedCity News September 10, 2024
Adding generative AI and other AI tools to coding and chart review practices streamlines a complex process and better positions plans for risk adjustment audits.
To tighten oversight and minimize overpayments to Medicare Advantage plans, the Centers for Medicare & Medicaid Services (CMS) introduced a new rule in 2023 that revamped the agency’s approach to risk adjustment data validation (RADV). The process involves scrutinizing claims data from a sample of plans against patients’ medical records to ensure alignment.
Incorrectly reported data or unsupported diagnoses may result in failed audits, repayment requests from CMS and potential legal consequences. Yet missed diagnoses also could lead to inaccurate member risk scores and an adverse impact on plan reimbursements. Medicare Advantage plans can meet...
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