Earlier this year, the Centers for Medicare & Medicaid Services (CMS) introduced new auditing procedures “committed to crushing fraud, waste, and abuse across all federal healthcare programs,” said CMS Administrator Dr. Mehmet Oz. One of the most significant changes affects all Medicare Advantage (MA) plans: CMS will now audit all eligible MA contracts annually, a major shift from its previous selective model. The number of plans audited is increasing from approximately 60 to over 500 per year. Each audited plan will be required to submit between 35 and 200 medical records, depending on the plan’s size.
Issuers of MA plans are rightfully concerned about how these changes will affect their organizations. “In past years, MA plan issuers might have thought they wouldn’t be one of the 35 plans selected for review,” explained Manny Martin, Vice President of Commercial Services at MetaStar, “but now that they know every eligible plan will be audited annually, they’re wondering, ‘Am I going to be ready? I need to be ready. How can I get ready?’”
The answer is simple: MetaStar’s Medicare Risk Adjustment Data Validation (RADV) Readiness service line, part of our broader Audit and Data Validation Readiness series. Combining over 50 years of healthcare quality improvement experience with deep knowledge of CMS requirements, MetaStar’s Medicare RADV Readiness will have you feeling capable, competent, and qualified. As Martin said, “If you don’t feel ready, we’ll get you ready.”
MetaStar’s Medicare RADV Readiness combines the benefits of a CMS-trained coder with the guidance of a trusted compliance advisor. Sitting proudly under the new umbrella of MetaStar’s Audit and Data Validation Readiness Series, Medicare RADV Readiness can help MA plans feel knowledgeable and in control before CMS arrives.
CMS uses RADV audits to verify that the risk-adjusted payments it makes to Medicare Advantage plans are accurate. These payments are based on diagnosis codes submitted by the plan, which CMS translates into Hierarchical Condition Categories (HCCs). Each HCC reflects the severity and cost of a member’s condition and contributes to a risk score. The higher the score, the more CMS pays the plan. This assumes the diagnosis is supported by clinical documentation. “It’s all about health plans receiving the appropriate amount of dollars based on the health risk score of each member,” Martin added.
It is a complex process, especially because many diagnoses are documented by providers outside of the health plan’s direct control. Add to that two coding frameworks (ICD-10 and HCC), varied provider documentation practices, and evolving CMS requirements, and the potential for financial risk becomes significant.
MetaStar has been a leader in the healthcare data validation and auditing space for years, which, as Martin explained, “speaks to our reputation, reliability, and the trust that our collective clients have placed in us.” MetaStar’s Medicare RADV Readiness has been specifically designed to help MA plans with the following core services:
MetaStar’s Medicare RADV Readiness also provides related essential services. As Ross Gatzke, RADV Practice Leader at MetaStar, explained, “It’s going to be challenging to track all the information coming in and moving around [during RADV Readiness]. We offer project management support and reporting as well as actionable insights based on what we find.” With their proprietary software and flexible reporting capabilities, MetaStar ensures all data is documented and securely shared with the appropriate stakeholders. MetaStar’s Medicare RADV Readiness also offers something priceless: peace of mind.
Additionally, the value of MetaStar’s Medicare RADV Readiness is objectivity while maintaining organizational independence. Gatzke has seen many clients expect their documentation to support the HCC diagnosis codes. “While the documentation is good,” he said, “our coders can identify gaps in the documentation that the [MA plan] may not be aware of.” By identifying these gaps before CMS arrives, MetaStar helps clients course-correct and build internal awareness that benefits future audits, not just the current one.
MetaStar’s years of experience performing data validation and audits translates into the ability to offer Medicare RADV Readiness clients a deeper understanding of requirements and regulations. “We have a team of certified coders that go through our data validation and audit training every year,” said Andrew Penning, AAPC-certified medical coder and senior audit analyst at MetaStar. “They have a wealth of experience with medical record coding and the guidance behind it.”
Another pride point for MetaStar is their technological capabilities. Their software is proprietary, so they can easily adapt to their customers’ needs rather than forcing them into rigid software. “We are very flexible in being able to leverage our in-house software development expertise,” Martin explained. Their robust collection of tools, applications, and back-end reporting are SOC 2® certified, facilitating secure data exchanges. This, combined with trained experts and over 50 years of experience in healthcare quality, creates an offering that you can’t find anywhere else.
In fact, Martin proudly announced that MetaStar’s Audit and Data Validation Readiness series is one-of-a-kind. “I do a lot of competitive research, and I have not seen one of our direct competitors provide this kind of structured, CMS-aligned readiness support,” he said. The Readiness Series, which will eventually be available for other audits and data validations, can help organizations feel more secure in their documentation before CMS sends a “Save The Date” notice
When it comes to CMS, MA plan audits, and increasing scrutiny on overpayments, it’s not just enough to know what’s happening—you need to be ready for it. MetaStar’s Medicare RADV Readiness offers more than just a review, more than just an answer. It offers RADV and coding experts with real-life and relevant experience, helping you feel confidently prepared. With proprietary software, personalized service, and top-tier trained experts, MetaStar is ready. Are you?
To start on your path to Medicare RADV Readiness, contact Manny Martin, Vice President of Commercial Services, at 608-441-8264 or mmartin@metastar.com today.
Manny Martin has been with MetaStar for just over three years. He enjoys tackling complex problems with his colleagues, building and mentoring his standout team, developing new product lines, and helping organizations find real-world, effective solutions. We’re not entirely sure when he sleeps.
Ross Gatzke, a ten-year MetaStar veteran, is a triple threat as the product lead for URAC Accreditation Data Validation, Initial Validation Audit, and now the Audit and Data Validation Readiness series. This jack-of-all-products is also a master of them all—he enjoys providing technical assistance, guidance, and support to both customers and colleagues.
Andrew Perring has been at MetaStar for over seven years. His favorite part of his job has been becoming a medical coding wizard and sharing his knowledge with medical wizards-in-training. Wands optional; knowledge of HCC coding is provided.