Certified Risk Adjustment Coder (CRC)

What is the primary purpose of a RADV audit?

1. To ensure compliance with federal regulations

2. To validate submitted HCC data

3. To conduct random checks on patient records

4. To assess provider performance and quality of care

The correct answer is: To validate submitted HCC data

The primary purpose of a RADV audit is to validate submitted Hierarchical Condition Category (HCC) data. This process involves reviewing the medical records and the corresponding documentation to confirm that the risk adjustment coding reflects the patient's actual health status accurately. Accurate HCC coding is crucial as it impacts the reimbursement rates for Medicare Advantage plans and ensures that providers are appropriately compensated for the care of patients with varying health conditions. Through this audit, discrepancies between the reported HCC codes and the actual clinical documentation can be identified and corrected, helping to ensure data accuracy, which is essential for maintaining the integrity of risk adjustment programs. It ultimately serves to ensure that the healthcare system is both fair and effective in compensating providers based on the complexity of patient care. While ensuring compliance with federal regulations, conducting random checks on patient records, and assessing provider performance are important components of healthcare administration and quality improvement, they are not the primary focus of a RADV audit. The main objective is specifically to verify the accuracy of the HCC data related to patient diagnoses, which directly influences funding and resource allocation in health plans.