What You Should Know:
Wolters Kluwer Health, a leading provider of healthcare information and analytics, has introduced a new weapon in the fight against potential financial penalties for Medicare Advantage Organizations (MAOs) – the Regulatory Audit Module.
– The AI-enabled tool leverages artificial intelligence (AI) to streamline the risk adjustment audit process, potentially saving MAOs millions of dollars.
The Challenge: A Complex and Costly Regulatory Landscape
Health plans, particularly MAOs, face a growing burden from complex regulations and stringent audits. The Centers for Medicare & Medicaid Services (CMS) estimates a staggering $4.7 billion in potential recoveries from Risk Adjustment Data Validation (RADV) audits through 2032. These audits assess the accuracy of risk scores assigned to Medicare Advantage beneficiaries, which directly impact reimbursement rates.
Manual Processes: A Recipe for Errors and Inefficiency
Traditional methods for preparing for risk adjustment audits are often manual and error-prone. Sifting through massive datasets to identify the most relevant medical records can be time-consuming and prone to human error. This can lead to missed opportunities to support accurate coding and potentially higher repayment liabilities.
The Regulatory Audit Module: Leveraging AI for Efficiency and Accuracy
Wolters Kluwer Health’s Regulatory Audit Module is designed to address these challenges head-on. This AI-powered solution offers several key benefits:
- Enhanced Accuracy: Clinically trained AI identifies an average of 5-7% additional codes that support accurate risk adjustment, potentially reducing repayment risks.
- Improved Workflow: Bypassing manual processes, the module automates tasks, presenting auditors with all relevant data points linked directly to the corresponding medical records.
- Prioritized Reviews: Embedded logic and AI prioritize charts based on a confidence score for each Hierarchical Condition Category (HCC). This allows auditors to focus on the most critical records for review, maximizing efficiency.
- Time Savings: The module streamlines the audit workflow by at least 25%, enabling MAOs to meet tight audit deadlines more effectively.
- Real-Time Insights: The module provides real-time data on coding and submissions, offering valuable insights into audit progress and potential financial impacts for all levels of leadership, from auditors to the C-suite.
“When we first launched Coder Workbench, we worked closely with our team of experienced clinical risk adjustment coders to deliver a solution that solved true pain points for both the end user and the C-suite. We’ve continued to lean on that expertise to develop the Regulatory Audit Module, combining essential industry insight with AI that, consistent with audit guidelines, recommends charts appropriate to submit to achieve higher validation rates and avoid costly penalties. There isn’t another tool on the market designed to help health plans effectively manage these challenges today,“ said Anne Donovan, Vice President and General Manager, Health Language, Wolters Kluwer Health.
