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What is a RADV?

  • In "FAQ: 10 Thinks You Need to Know About Risk Adjustment, Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP, explains:
    CMS uses two main types of risk adjustment data validation (RADV):
    1. 1. Random CMS RADV uses a selection process in which a Medicare Advantage (MA) plan is randomly selected for an audit.
    2. 2. Targeted CMS RADV is applied to MA plans who have raised red flags, such as a large increase in risk scores, etc.
    Both random and targeted CMS RADV use a “stratified sample,” which is a random sample of one-third of patients with high-risk scores, one-third of patients with medium risk scores, and one-third of low risk scores. The focus is not proving the ICD code, but rather proving the validity of the HCC value that was paid to the health plan by CMS for the reported ICD code.
  • Suggested reading: "RADV Reality," by Tom Nasadoski, MBA

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