BillingParadise Presents
Risk Adjustment Fraud , Not Just Another “F” Word
Is Your Practice At Risk For An Audit?
posted by Holly Cassano & Kim Dues for Billing Paradise 24/7
This webinar will discuss RADV Audits, which pertain to Risk Adjustment and how Providers and Coding Professionals, must understand, that they too, can be on the hook in the event a Medicare Advantage Plan is audited and found to have deficiencies.CMS performs Risk Adjustment Data Validation (RADV) audits by reviewing provider medical record documentation to validate submitted diagnoses codes, as they correlate to HCC codes.United Healthcare, Freedom Health, Humana & Aetna and Optimum Healthcare, currently are all in the scope of the DOJ for allegedly submitting risk adjustment scores that improperly inflated their Medicare Advantage reimbursement, HealthLeaders Media recently reported.
Risk Adjustment Factor Scoring or (RAF), when properly reported, allows CMS to provide additional reimbursement to Medicare Advantage Plans, based on a Members’ overall health. The RAF scores, are derived from the submitted diagnoses from what should be in the medical record. Higher weighted RAFs, correlate to sicker patients, which means a higher cost to the MA Plan to treat these sicker patients, hence, requires higher reimbursement to the MA Plans.
The main avenue in which Risk Adjustment Fraud and Abuse occurs, is by reporting chronic conditions and subsequent treatment, on patients that did not have the reported conditions or care, or upcoding on existing conditions, to make it seem more severe in nature than it is.
At the Q&A session following the live event, ask a question and get advice unique to your situation, directly from your subject matter experts.
About the Speakers
Holly Cassano
CPC, CRC, AAPC, ICD-10-CM Certified
Over 21 years proven experience in the healthcare industry.
Experience: Auditing- Government & Commercial/Risk Adjust/HCCs/RADV/Mgd Care Contracts/AR/Practice Management/Public Speaking/OIG Compliance, Fraud & Abuse/ICD 10 /Professional Healthcare Blogger.
Specialties: Risk Adjustment-HCC ( was one of 7 people invited by the AAPC, in 2014, to help develop what is now the Certified Risk Adjustment Coding Credential – The CRC and helped them develop the CRC National Exam.
Holly is well versed in many specialties, including the following: Emergency/Orthopedics/Spine Surgery/ Gen Surgery/Spine Surgery/Pediatrics/Cardiology/Family,Internal,General Medicine/Physical Therapy/Bariatrics Plastics/Anesthesia/Psych/ Behavioral Health/ Urgent Care/ Gastro/Endo/ENT/Psych/Neurology/Obgyn.
Holly had her own column in Healthcare Fraud and Abuse with Advanced for Healthcare Information Technology and has authored many articles on Fraud and Abuse, along with some groundbreaking articles on Risk Adjustment and HCC’s, for the AAPC, JustCoding.com and for Medicalbillingandcoding.com.. She authored the ABC’s of HCC’s in 2011, which has been utilized as a baseline tool for HCC Capture by many in the industry. She authored the Risk Adjustment course original content for Coding Certification CCO, and she also worked for a Medicare Advantage Plan for several years, Preferred Care Partners, based out of The Villages, FL, as well as for Cleveland Clinic, Weston FL, before starting her own consulting company in 2012.
She was interviewed by PBS Newshour in 2013 regarding the ICD 10 changeover. She has presented on Risk Adjustment for Opal events in 2012 & 2015 and at the Rise Conference in Miami, December 2015. She is an active Member of the CMS Provider Outreach Program(POE), in Florida, for First Coast Service Options (FCSO) and was part of the initial group of folks who help FCSO develop what is now Medlearn on the CMS website
She has served two terms on her local AAPC chapter in Sunrise, Florida.
Kim Dues
CPC, CRC, AAPC, ICD-10-CM Certified
Kim’s experience includes over 24 years in the healthcare field. She currently serves as Regional Director of Quality Assurance, Client Services, RCM for Anesthesia and Risk Adjustment for Billing Paradise 24/7. Kim is an expert with Practice start-up and Practice Management, with an extensive background in Anesthesia and Pain Management. Kim also has a significant background as a duly licensed insurance-securities agent,where she negotiated Health, Accident, Life and Variable Security products for small business. She is an active member of the AAPC.
Kim is also well versed in the following specialties: Obgyn, HCC/Risk Adjustment, General Surgery, Orthopedics, Chiropractics, Radiology, E&M Documentation, Payment Reconciliation, Posting/Bank Statements/Lockboxes, Physical Therapy, DME, ZPIC Audits, Commercial Payer Audits,
Presented with Holly Cassano, CPC, CRC, ICD 10-CM, at the Rise Risk Adjustment Conference, Dec 2015, Miami, Florida
Kim has also presented at several Anesthesia and Medical Billing conferences in past years
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Also See: Presentation on How to Encounter CMS & HHS RADV Audits [CEU]
The post Risk Adjustment Fraud, Not Just Another “F” Word [Webinar] appeared first on BillingParadise.
This post first appeared on CMS Audits For Risk Adjustment – Will RADV Be Upgraded And Intensified POST UNITED, HUMANA, FREEDOM, please read the originial post: here
