CMS Responds to Physicians’ Concerns with RADV Audits

The Pennsylvania Medical Society (PAMED) recently received many inquiries from its members related to Medicare Risk Adjustment Data Validation (RADV) audits, specifically regarding the number of records being requested.

RADV audits are not unusual and happen across the state, but it appeared that the number of records being requested from some practices was unusually high. The cost to practices to produce these records includes staff time to pull and copy the charts and actual copying expenses. So, naturally, physicians were concerned.

On physicians’ behalf, PAMED reached out to the Centers for Medicare and Medicaid Services (CMS) with these concerns. CMS responded that it is aware of the medical record acquisition issues as raised by PAMED and some of its members. It also said that:

  • Medicare Advantage (MA) organizations that have been selected by CMS for payment validation audits, along with their contracted providers and practitioners, are legally required to provide medical records for the validation of risk adjustment data.
  • Generally, under an RADV audit, medical records are requested for a sample of 201 enrollees.
  • In circumstances where an MA organization is requesting medical records for a non-CMS initiated activity, the MA organization and its contracted providers are held to the terms of their contract.
  • MA organizations may only use official CMS correspondence when requesting  the submission of medical records for RADV audits initiated by CMS. CMS also said that it recognizes that providers may have difficulty knowing when a request for medical records from an MA organization is a CMS-initiated request or a plan-originated request. It said that providers can identify a request for medical records that originates from CMS by way of an accompanying CMS letter (i.e. a letter on CMS letterhead that is signed by a CMS official) explaining that the requested medical records are needed for a CMS-initiated RADV audit.
  • Regarding whether CMS could offer financial assistance for the costs of providing medical records, by law, CMS is not allowed to require a particular price structure for an MA organization’s contract with other entities, which means that it cannot required MA organizations to make payments to providers for submission of medical records. It also said that CMS does not have a contractual relationship with the MA organization’s contracted providers, and that such payments would have to be a subject of negotiation between the MA organizations and its contracted providers.

PAMED continues to take physician concerns such as this to the appropriate organizations. Having an issue in your practice? Call our Practice Support Team at (717) DOC-HELP for individualized assistance, that’s (717) 362-4357.

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