November 20, 2023
Understanding Risk Adjustment Audits and Requests for Records
from AOA Practice Success

Doctors of optometry often receive records requests related to the Medicare Advantage Risk Adjustment Data Validation (RADV) program. These are different from typical audits doctors receive to ensure that proper payment was made to the doctor. These audits are the primary way for the Centers for Medicare & Medicaid Services (CMS) to address improper overpayments to Medicare Advantage Organizations (MAOs). During a RADV audit, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee's medical record. Health plans need help from doctors to submit documentation to CMS.

Steps for Responding to Risk Adjustment Audits
  • Confirm it is a Risk Adjustment Audit - To ensure that this is not a standard audit, ensure that ‘risk adjustment’ is noted in the records request.
  • Contact the Requesting Agency - Plans often request a very large number of charts (more than 1000 in some cases). AOA recommends that doctors reach out to the requesting agency and confirm how many records are needed to be responsive to the request. Doctors and their staff should also ask for information regarding how to be reimbursed for time/effort spent in responding to the request. Some plans have specific forms that need to be submitted for doctors to be paid and others have different processes.
  • Don’t Ignore Risk Adjustment Audits - Respond in some way to the request, even if it is to ask for an extension to the deadline provided by the plan.

Need Help?
If you have questions about how to get reimbursed for time/effort spent in responding to records requests, contact stopplanabuses@aoa.org
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OD OF THE YEAR
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Troy, Alabama
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Hoover, Alabama
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Albertville, Alabama
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ALOA Board 2023-2024
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