Recent healthcare audit activity and enforcement actions underscore growing compliance risks for healthcare providers—particularly in Medicare Advantage (MA) documentation.
PYA Principals Valerie Rock, Bob Paskowski, and Kristy Evans offer insights on these risks in a recent issue of Report on Medicare Compliance. The article, “RADV Audits of MA Plans Put Providers on The Spot; ‘Not All Diagnoses’ Are in One Place,” written by Nina Youngstrom, features expertise they shared during a PYA webinar, “CMS Enforcement to Provider Risk: The Downstream Impact of RADV Audits.”
The PYA leaders state that risk adjustment data validation (RADV) audits are increasing financial and compliance exposure for providers when diagnoses lack sufficient documentation.
“Everything starts and stops with provider documentation,” Evans says, emphasizing that accurate, encounter-based records determine whether reported diagnoses withstand scrutiny and avoid provider repayment tied to unsupported coding.
Paskowski adds that risk adjustment drives MA reimbursement based on diagnoses and prior claims data, making accurate documentation essential, and warns that MA overpayments could be pushed down to providers.
An additional complexity comes from shared patient care, Rock explains. “Just because you’re submitting claims doesn’t mean you’re the only one serving that patient,” she says. Because diagnoses may be supported across different settings and providers, responsibility for documentation is not always straightforward.
Common mistakes that elevate risk include outdated condition lists, a lack of specificity in coding, and gaps between documented care and billed services. The PYA leaders urge providers to employ strong documentation practices, aligned coding, and awareness of shared accountability to successfully navigate increased audit scrutiny.
Read the full article about RADV audits by subscription on HCCA’s website or access a PDF of the article.
Report on Medicare Compliance is produced by the Health Care Compliance Association (HCCA) to provide updates on compliance strategies specifically pertaining to Medicare.
For more than 40 years, PYA has helped healthcare providers understand and comply with governmental regulations.
