Medicare Advantage, ACA & Medicaid Risk Adjustment
Robust Programs for Complete, Accurate & Compliant Submission
ATTAC’s risk adjustment experts help health plans, provider organizations and vendors implement effective risk adjustment programs for Medicare Advantage, commercial, ACA and Medicaid.
We’re one of the nation’s leading risk adjustment auditors for ACA HHS-RADV audits and Medicare Advantage risk adjustment audits and reviews.
Risk adjustment impacts the bottom line, and ensuring complete and accurate diagnosis capture and reporting of illness burden is critical. ATTAC’s experts can help you implement an effective and compliant program.
ATTAC’s Risk Adjustment Case Studies & Capabilities Brochures
Medicare Advantage RADV Audits, Compliance & Overpayments
Risk Adjustment Auditing
- ACA HHS-RADV Initial Validation Auditing (IVA)
- Chart Over-reads & Vendor Validation
Risk Adjustment Program Development, Optimization & Compliance
Risk Adjustment Program Design & Optimization for Providers
What is MA-RADV?
Within the Medicare Advantage (MA) Program, inaccurate diagnoses can lead to inflated medical expenses and inappropriate overpayments to Medicare Advantage Organizations (MAOs). That’s where risk adjustment comes in.
Risk adjustment is a methodology used to determine what to pay a health provider by assessing the anticipated use of healthcare services by their enrolled beneficiaries and evaluating the enrollees’ expenditure on health services.
The Centers for Medicare & Medicaid Services (CMS) uses the Medicare Risk Adjustment Data Validation (MA-RADV) program to protect the integrity of the MA program and prevent issues such as overpayments to MAOs. Through the MA-RADV program, the CMS ensures equitable compensation for participating healthcare providers like doctors by meticulously analyzing the health status of Medicare patients.
Besides leveling the playing field for healthcare providers by adjusting payments based on patient health complexity, the CMS also uses the MA-RADV to:
- Establish financial incentive structures in models influencing Medicare payments.
- Determine fixed, per-patient payments for healthcare providers based on pre-calculated risk scores instead of per-service reimbursement.
To ensure the accuracy of diagnoses submitted by MAOs, the CMS conducts rigorous auditing. Following the final risk adjustment data submission for the MA contract year, the CMS commences MA-RADV auditing, culminating in potential payment adjustments after recalculating affected individuals’ risk factors.
Discrepancies in risk adjustment emerge during MA-RADV audits when CMS auditors, reviewing medical records, find inconsistencies between an enrollee’s reported Hierarchical Conditions Categories (HCCs) for payment (based on MAO self-reported data) and their actual diagnoses. By consolidating these discrepancies across cases, the CMS quantifies the overall level of potential payment error within the audited MAO.
Overall, the MA-RADV program promotes fairness and fiscal responsibility within the MA program. By preventing improper overpayments based on unreliable data, it protects the financial integrity of the program, safeguarding the well-being of its beneficiaries.