UnitedHealthcare Implementing Risk Adjustment Audit Program

Beginning in June 2018, UnitedHealthcare (UHC) will implement their risk adjustment data validation (RADV) audit program. UHC states that through the mandatory requirement by the U.S. Department of Health and Human Services (HHS), Medicare Advantage health plans will be reviewed for supporting medical documentation to check for accurately reported patient data. UHC will send requests for medical records through their vendor, CIOX Health, to a random selection of providers within a specified 2017 service date range.

UHC announced the implementation of the audit program in their May 2018 Network Bulletin, citing that they are working to be compliant with the RADV audit program under the Affordable Care Act, where insurance companies should be making annual and random spot checks that patients’ health status and diagnoses are accurately reported.

Unlike traditional managed care audits, which examine billing or medical necessity, risk adjustment audits are much narrower in focus and based on confirming the basic health status and diagnosis of randomly sampled patients. If one of your patient claims is in the sample, you will be contacted to submit the requested documentation in the medical records, which may include:

• Demographics sheet
• Progress notes/face-to-face office visits
• Consultation reports/notes
• Emergency records
• History and physical exam
• Medication list
• Operative/procedure notes
• Prescription for laboratory services
• Problem list
• Radiology and pathology services
• Radiology reports

It is recommended for practices to not send records in response to a risk adjustment audit until the required notice under 56.104 is received, which specifies the therapy information being sought as well as the intended use of that information. Make sure to confirm the request is for a risk adjustment or traditional managed care audit, and assign a staff member to extract and review the necessary information before sending to the insurance company.

For questions or additional information on audit or coding guidelines, contact the ACR practice management department at practice@rheumatology.org.