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How to project manage a successful risk adjustment data validation audit

Ahmed Salim (ahmed.salim@irhythmtech.com) is Director of Ethics and Compliance at iRhythm Technologies in Lincolnshire, IL, and Palak Desai (pdesai14@mail.depaul.edu) is a student at DePaul University College of Law in Chicago.

If you’re a Medicare Advantage organization, there are few terms scarier than a Risk Adjustment Data Validation (RADV) audit from the Centers for Medicare & Medicaid Services (CMS). CMS routinely conducts two types of RADV audits:[1]

  • “Annual [national-level] audits to estimate the national [Medicare Advantage] improper payment rate” and

  • “Contract-level RADV audits to identify and recover improper payments from [Medicare Advantage] organizations.”

Audits from CMS are both random and targeted and involve a great deal of cross-functional communication and support from a variety of departments within an organization. An RADV audit can last several months and can use a number of resources to be completed. To ensure RADV audit deadlines and goals are met, it is important that an organization project manage an RADV audit in order to provide clarity and structure to all stakeholders involved. Project management consists of the following:

  1. Identification and appointment of a project manager,

  2. Development of a project plan, and

  3. Communication between stakeholders.

It is important to spend time organizing the management of your RADV audit prior to the start of it to help yield positive output from all stakeholders involved within your organization’s RADV audit. It is equally important to identify all goals and deadlines to ensure success.

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