Lessons Learned from a RADV Audit Report

November 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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If given an opportunity to know ahead of time the questions that would be asked of you in an upcoming interview or quiz, it is likely the outcome would be significantly better than if you were surprised by the questions. This same concept may be applied to audits of risk adjustment claims and other medical services. Each year the OIG identifies areas of vulnerability for providers and payers and then audits these vulnerable areas to identify possible overpayments. 

A careful review of the OIG’s annual Work Plan can help organizations strategize and direct internal auditing resources. All efforts should be made to identify weaknesses and overpayments and correct them under the direction of legal counsel.

An OIG report from May of 2021 includes the findings from a 2015-2016 RADV audit on Anthem Community Insurance Company, Inc., a prominent Medicare Advantage Organization (MAO) providing benefits to a large number of Medicare beneficiaries. This report identifies the areas where the OIG feels Anthem either made errors, inappropriately reported, and were paid for diagnoses that were not supported by the medical record.

Risk adjustment is a mechanism for financing health care that is based on the level of risk associated with providing healthcare coverage to individual beneficiaries. The health of each beneficiary is assessed through the provision of healthcare services, which are documented by the treating healthcare provider. Documentation includes and must support any diagnoses reported for the patient using the ICD-10-CM codeset, following the official coding guidelines. Each ICD-10-CM code is assigned a hierarchical condition category (HCC) code, which carries a specific value. When all assigned HCC values have been summed for a given reporting period, a total risk is identified by which funding is determined. All diagnoses must be supported by the medical record and coded according to the ICD-10-CM coding guidelines. Risk Adjustment Diagnosis Validation (RADV) audits are performed by the government to identify overpayments caused by improper ICD-10-CM code assignments either due to a lack of medical documentation to support the assigned code or failure to properly apply the coding guidelines during the code assignment process. 

In this particular report, the OIG identified several problems they believe caused overpayments for which they are demanding repayment. Reports like these are valuable auditing tools as they: 

  • identify problematic diagnoses 
  • cite coding and documentation criteria the OIG is looking for
  • detail counter arguments by the payer 
  • provide insight into the issues the OIG has discovered with certain high risk diagnoses helping payers set improved compliance standards
  • present an overall picture of how to formulate and argue points of contention
  • provide a list of diagnosis codes, guidelines, and provider documentation issues that should be addressed to avoid similar auditing outcomes 

For example, this report highlights the need for providers to document with greater detail a more complete diagnosis when available, as arguments were made on both sides regarding how to properly report mild depression with the OIG stating is should be reported as “depressive disorder, not otherwise specified” while Anthem argued supporting documentation concludes it was “major depressive disorder, mild.” While it may seem like a minor issue, this particular argument could result in repayment of $10,786 if not correctly reported.


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