In RADV audit context, what does 'overpayment' refer to?

In the context of a RADV audit, 'overpayment' specifically refers to payments that exceed the support provided by submitted diagnosis codes. This is a crucial concept in risk adjustment data validation, as it directly relates to the accuracy of the data submitted by healthcare providers.

When a health plan submits diagnosis codes to reflect the health status of its members, those codes are used to determine the payments made to the plan based on the risk profile of its enrollees. If the payments received are based on diagnosis codes that are not sufficiently substantiated by medical records or do not accurately reflect the actual health conditions of the patients, this can lead to overpayments.

This distinction is essential for ensuring that healthcare organizations are not receiving financial compensation for conditions that are not valid based on the coding guidelines and support. Overpayment in this sense emphasizes the need for precise documentation and adherence to coding standards, ensuring that resources are allocated appropriately and that the financial integrity of risk adjustment programs is maintained.

Understanding this definition helps in grasping the broader objectives of RADV audits, which aim to ensure that payments made to providers are justified and appropriate based on accurate diagnosis representations.