The Risk of Clinical Documentation Audits

The overwhelming majority of MA and Marketplace plans and their delegated provider entities are aware of how onerous a RADV or IVA audit can be on their operations and long-term financial viability.  The potential for negative revenue implications, particularly for the Marketplace IVA audits is real.  IVA audits begin in earnest in 2017, with 2016 serving as the one and only practice year.  CMS is considering turning over responsibility for Medicare-Advantage RADV audits to private Recovery Audit Contractors who will pursue unsubstantiated HCCs on a contingent fee basis!

Most plans do not have a handle on how their providers’ clinical documentation will stand up to audit.  Do the clinical narratives created by your clinicians adequately substantiate the diagnosis codes that are ultimately submitted to the payer entity?  Or do your physicians and mid-level practitioners need additional training to ensure that morbidities are documented in the optimal portion of the medical record, with a clear linkage between the diagnosis and treatment?

Oftentimes provider groups and plans do not know whether there are additional HCCs (or CDPS categories, Johns Hopkins ADGs, etc.) that could be extracted from medical records, if only providers improved their clinical documentation.  Plans often default to the low-hanging fruit of closing last year’s risk adjustment gaps.  This approach can be fraught with risk because many of last year’s gaps are likely to resolve become less severe (e.g., diabetes with acute complications, sepsis, sequelae of CVA, etc.).

The Mile High Healthcare Consulting Solution

Mile High Healthcare Consulting has supported plans and providers by assessing the validity of clinical documentation and its impact on risk scores and premium levels.  Working with one of our CDI partners, we have an approach that involves examining a statistically valid sample of medical records to ascertain the quality of the medical record while also examining ancillary portions of the record (e.g., lab results, diagnostic testing, imaging results) for “provisional HCCs” that, only if documented correctly, would result in a more accurate relative risk score.