In this episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker take a deep dive into the world of Risk Adjustment Data Validation (RADV) audits. These audits have become an increasingly high-stakes area of focus for healthcare compliance professionals navigating today’s regulatory landscape and this conversation will help you understand them on a deeper level.

Throughout this episode, your hosts cover the purpose and impact of RADV audits, including how CMS uses them to ensure billing accuracy and recover overpayments. With annual audits now planned for every Medicare Advantage plan, the pressure on healthcare organizations to maintain accurate documentation has never been greater.

You’ll also learn how RADV audits are conducted, from record sampling to final closeout meetings, and why internal review and proactive documentation are vital. Jessica, Lorie, and Levan also explore the real-world challenges of responding to multiple audits at once, highlighting strategies to stay ahead of the curve.

Additionally, this episode looks at how emerging technologies like AI and data analytics can streamline the audit process. By leveraging the right tools and team, organizations can better manage risk, reduce financial exposure, and maintain compliance in a rapidly evolving environment.

Key Takeaways:

• RADV audits are used by CMS to validate diagnosis coding and ensure proper reimbursement.
• The audit scope has expanded significantly, now including all Medicare Advantage plans annually.
• Inaccurate coding can lead to major financial recoupments and increased compliance risk.
• The audit process includes multiple phases, from sample selection to dispute resolution.
• AI and advanced analytics can help identify vulnerabilities and improve audit readiness.
• Proactive planning, training, and documentation are critical to navigating RADV audits successfully.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

Jessica, Lorie, and Elvan (your favorite Compliance professionals) are back with another installment of Compliance Deconstructed and In this insightful episode, they explore the growing role of Artificial Intelligence (AI) in detecting and preventing healthcare fraud. With healthcare systems facing persistent issues of fraud, waste, and abuse, AI offers new tools to identify patterns, flag anomalies, and streamline compliance efforts.

The discussion dives into how AI can both help and hinder fraud detection, acting as a powerful tool for compliance or a potential risk when exploited by bad actors. Real-world examples illustrate how AI identifies unusual billing patterns or fabricated documentation that may warrant further investigation.

Jessica, Lorie, and Elvan emphasize the importance of human oversight in AI-driven systems, especially to prevent bias and ensure ethical use. They also discuss the risks of using AI in processes like prior authorizations, where automation must be carefully balanced with clinical judgment.

To wrap up, the episode offers a practical guide for healthcare organizations looking to implement AI responsibly. The key message: AI is not a silver bullet, but with careful deployment and continuous monitoring, it can significantly enhance fraud prevention while safeguarding fairness and patient care.

✅ Key Takeaways

• AI can rapidly analyze claims data to detect unusual billing patterns and potential fraud.
• Criminals may also use AI to commit fraud, making it a double-edged sword.
• Natural Language Processing (NLP) enables AI to review documentation and identify inconsistencies or deceptive language.
• Bias in AI systems is a real risk and must be addressed through diverse training data and human oversight.
• AI in prior authorizations can speed up approvals but must be carefully monitored to avoid inappropriate denials.
• Successful implementation of AI for fraud detection requires a step-by-step approach, including data quality, oversight, and transparency.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.

We’re back for Episode 5 of Compliance Deconstructed and today, Jessica Zeff, Lorie Davis, and Elvan Baker explore how recent fraud investigations and emergency response funding missteps impact healthcare compliance. They emphasize the importance of understanding fraud, waste, and abuse regulations to reduce risk and protect patient care quality.

Throughout this conversation, the ladies discuss the Department of Justice’s investigation into United Healthcare for alleged upcoding practices to inflate reimbursements. This case highlights the critical need for transparency and the potential consequences of manipulating patient data.

Even smaller providers are subject to the same level of scrutiny from regulatory bodies like the DOJ and OIG. Real-life examples show how individual practitioners have faced prison time for submitting fraudulent claims, reinforcing the importance of personal accountability.

Proactive compliance is a recurring theme, including tips for building a compliance work plan and reviewing the OIG Work Plan regularly. This episode addresses the significance of emergency preparedness, especially when handling federal funds during crises like the COVID-19 pandemic.

Key Takeaways:

• United Healthcare is under DOJ investigation for alleged upcoding and Medicare fraud.
• Fraud, waste, and abuse violations can lead to substantial penalties and reputational harm.
• Small providers and individual clinicians are not exempt from regulatory oversight.
• Proactive auditing and documentation demonstrate compliance intent to regulators.
• Emergency preparedness must include clear protocols for managing relief funds.
• Creating and maintaining a compliance work plan helps identify and mitigate organizational risk.
  
  

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.