When can a RADV audit lead to payment recovery?

A RADV audit can lead to payment recovery when discrepancies exist between the diagnoses reported and the clinical documentation. This is because the purpose of a RADV audit is to verify that the diagnosis codes submitted for payment accurately reflect the patient’s health status and the services provided. If the clinical documentation does not support the diagnoses as coded, it indicates that the claims may have been submitted based on inaccurate or misleading information, thus potentially leading to overpayments. The audit assesses whether the reported data aligns with the actual care received by the patient, and significant inconsistencies can trigger a recovery of funds that were improperly paid.

The other options do not directly relate to the criteria for payment recovery within the context of a RADV audit. For example, while approval of all submitted claims may reflect compliance, it does not guarantee that payment recoveries will not occur based on underlying discrepancies. Additionally, documentation of service mismanagement could be relevant in a broader auditing context but does not specifically pertain to payment recovery based on diagnoses. Similarly, audit scores potentially falling below a threshold indicates performance issues but does not inherently dictate payment recovery unless those scores stem from diagnosed discrepancies.