Who would typically be involved in the RADV audit team from a health plan perspective?

The RADV audit team typically includes coding specialists, compliance officers, and clinical staff due to their critical roles in ensuring accurate documentation and coding of patient data. Coding specialists are essential for verifying that the diagnosis codes recorded in patient records are accurate and align with the services provided. Their expertise helps confirm that the data submitted for risk adjustment is appropriate, as improper coding can lead to incorrect risk scores and potential financial penalties for the health plan.

Compliance officers are pivotal in overseeing that the health plan adheres to regulatory requirements related to risk adjustment and data reporting. They ensure that the processes and procedures meet the standards necessary to avoid violations during audits.

Clinical staff also play a vital role as they can provide insights into patient care and outcomes, further substantiating the validity of the clinical data submitted. Their involvement ensures that the medical records reflect the true severity and complexity of the patient population served.

Involving this combination of specialists ensures a comprehensive approach to the audit process, as they can effectively assess, interpret, and enhance the integrity of the risk adjustment data.