Compliance, Fraud and Abuse Prevention, and Program Integrity (RADV)
Program integrity and audits
Risk-adjustment compliance rests on accurate, supported documentation. The False Claims Act, Anti-Kickback Statute, and Stark Law frame improper billing and inducements; HIPAA governs privacy and data handling. RADV (Risk Adjustment Data Validation) audits compare submitted HCCs to medical records, use statistically valid samples, calculate error rates, and may extrapolate findings across the population, producing refunds and penalties. The 60-day overpayment rule requires return of identified overpayments.
Reviewers must avoid upcoding, unbundling, cloning, and coding without medical necessity. An audit-ready program has written policies, training, query logs, correction processes, and exclusion-list screening. Documentation improvement should never invent a diagnosis the provider did not document.
Traps: confusing RADV with quality or Star audits; assuming every documentation error is fraud (intent and knowledge matter); believing a chart review can add an unsupported diagnosis; and missing that sampling and extrapolation can magnify a small error rate.
Rule of thumb: every submitted HCC should survive a blinded re-review. Worked example: RADV finds the chart supports only "history of" the HCC condition. The HCC is removed, the error is counted, and the plan may owe repayment.