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How retrospective audit solutions are helping health plans safeguard from CMS penalties

The goal of a retrospective audit solution is to deep-dive into claim data comparison and underline and validate high-risk areas based on adjudication results.

With the approaching deadline of the 2022 Interim Final Run, is your health plan organization still struggling to ensure accurate data submission to the Centers for Medicare & Medicaid Services (CMS)?

With so many methods of performing a chart and audit process, health plans need to adopt the latest risk adjustment HCC coding technology to ensure utmost data accuracy and efficiency, especially when the claim submission deadlines are nearing, and to withstand those CMS audits.

Firstly, let’s know the types of audits by CMS:

  • RADV (Risk Adjustment Data Validation) Audit
  • OIG (Office of Inspector General) Audit
  • IVA (Independent Validation Audit) Audit

The Medicare organizations are being sent an audit notice by CMS mostly because some diagnoses at higher risk are being miscoded, leading to overpayments made by CMS to the health plans. 

The purpose of the audit notice is to review the accuracy of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) & Hierarchical Condition Category (HCC) codes that an MA organization has submitted to CMS.

A retrospective audit solution is a boon to health plans who have already received an audit notice from CMS, as well as, and HCC medical coders who want to ensure accurate chart review & audit before claim data submissions to CMS.

A retrospective audit solution is helpful to:

  • Safeguard against federal and payer audits, malpractice litigation, and health plan denials
  • Educate providers on Federal documentation guidelines      
  • Ensure the organization’s policies are current and effective
  • Elevate Payment Integrity.

Click to know how RAAPID.AI is helping Health plans and providers with Retrospective Audit Solutions.

Importance of accurate Coding & Auditing Solutions for CMS Claim Data Submission

A first-level review, also known as, a first-pass review, or even a periodic audit is recommended to ensure medical coders’ skills levels are as per the latest guidelines and ensure accuracy with those ICD-10-CM and HCC codes while determining the risk adjustment factor (RAF) scores.

As mentioned above, CMS has its independent companies Recovery Audit Contractors (RAC) to review the accuracy of claims. Therefore, as a health plan organization, you may want to adopt the latest AI technology risk adjustment HCC coding solutions to validate the coder’s findings, perform claim comparisons and get the final HCC summary along with accurate RAF scores before claims data submission to CMS.


RAAPID is offering AI-based Risk Adjustment Coding Solutions specially designed for healthcare payers, healthcare providers, and medical coders.

Powered by natural language processing (NLP) technology, RAAPID’s HCC Capture will allow health plans and medical coders to:

  • Capture accurate HCC codes with MEAT, in a chart review process
  • Automate HCC coding workflow
  • Increase transparency amongst HCC coders.

In addition, RAAPID’s HCC Compass is helping MA organizations to:

  • Adopt Retrospective Audit Solution and be prepared for CMS audits
  • Access to summary report to track added & deleted HCC codes
  • Submit accurate HCC data to CMS.

Call us at +1-502-498-4018 (Ext. 455) and speak to an expert, or get started now!


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Disclaimer: All the information, views, and opinions expressed in this blog are inspired by Healthcare IT industry trends, guidelines, and their respective web sources and are aligned with the technology innovation, products, and solutions that RAAPID offers to the Risk adjustment market space in the US.