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Retrospective Audit: How RAAPID.AI is helping Healthplans & Providers

An AI-Based Risk Adjustment Coding solution does more than simply identify bad claims to fix them, it allows Medicare Advantage (MA) organizations to enhance the HCC coding process and optimize revenue whilst ensuring quality patient care.

Retrospective audits offer the advantage of ensuring appropriate medical data submission to the Centers for Medicare & Medicaid Services (CMS).

It allows the billing compliance team to review submission claims, while uncovering troubling trends or worrisome providers.

In addition, it enables the MA organizations to get to the major root cause of any problems uncovered – and ensure comprehensive corrective action in the impacted areas.

Why Are Retrospective Review and Audit Important?

The (CMS) and the OIG encourage all healthcare providers to regularly have their coding reviewed by an independent party proficient in their clinical specialty.

Regular HCC coding audits provide many benefits including:

  • Ensure that your HCC coding is as per the Federal Guidelines
  • Identify under-coding to avoid possible claim denials 
  • Identify areas of compliance concerns

A Retrospective audit process is allowing healthcare MA organizations quickly identify and prevent compliance and ensure HCC coding improvement opportunities for accurate claim data submissions to the CMS.

Key Benefits of RAAPID.AI Retrospective Audit Solutions

1. Eliminate improper reimbursements from CMS

The most common causes of improper Medicare reimbursements include lack of documentation and incorrect HCC coding. A Retrospective Audit Solution can uncover improper diagnosis codes, whether caused by error or fraud.

2. Maintain Compliance

With new medical coding and reporting guidelines being released by the CMS continuously, staying compliant is still challenging for many MA organizations. With modern HCC coding and reporting solutions ensure your organization adheres to the new laws and regulations.

3. Improving Accuracy

Accuracy in HCC coding is essential to avoid compliance consequences, improper medical records data submission, and overall quality of care. For example, medical coding affects healthcare organizations’ quality reporting and risk adjustment.

A Retrospective Audit can identify poor documentation that affects HCC coding quality and becomes a challenge for medical coders to ensure accurate RAF scores.

Also, accuracy in medical coding for quality reporting is becoming increasingly important as the requirements for value-based reimbursement evolve.

4. Retrospective Audit Eliminates Inaccurate Coding

Inaccurate HCC coding leads to MA organizations with inappropriate reimbursements. Moreover, inaccurate HCC coding can result in denied and rejected claims.

A Retrospective audit Solution will identify gaps in the medical coding process that lead to a loss in revenue. This way, MA organizations can enhance their HCC coding workflow to avoid a future loss to the bottom line.

When To Conduct a Retrospective Audit?

Experts recommend an external coding audit at least once a year, but there are healthcare organizations that commit to frequent external coding audits to reap as much benefit as possible.

Frequent medical coding audits help MA organizations track errors at regular intervals, which in turn allows for rectifying the errors resulting in lost revenue. Also, it will help medical coders stay up to date on the latest regulatory requirements and help them avoid common errors.

Annual reviews offer a retrospective for 12 months, but MA organizations may need to make updates to their processes more often to make adjustments sooner rather than later.

Take Away

Opting for a first-level review or looking for a second-pass review will help your MA organization achieve a high return on investment (ROI), whilst performing the best HCC coding practices for the growth of your organization.


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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.