NewWave’s Greg McGuigan, Executive Vice President, and former Deputy Director for the Data Systems...
Medicare Risk Adjustment Data Verification (RADV)
Fighting Improper Health Claims through Risk Adjustment Data Validation (RADV) Analysis at the Centers for Medicare and Medicaid Services (CMS)
The Risk Adjustment Data Validation (RADV) program is used by the Centers for Medicare and Medicaid Service (CMS) to perform audits on Medicare Advantage Organizations (MAO) to ensure proper payments have been applied to each sample organization and subsidiary contract.
NewWave has led the operations and maintenance of RADV by performing the RADV process and by supporting the modernization of the Central Data Abstraction Tool (CDAT) which automates and tracks all the requests received by the Medicare Advantage Organization (MAO) Contracts in the RADV program.
RADV was developed to support risk data validation for better care and payment integrity at the Centers for Medicare and Medicaid Services, where invalid claims were leaving the Medicare Advantage system with a loss of an estimated $60 billion, annually.
The Centers of Medicare and Medicaid Services required a systems integrator to support its Centralized Data Abstraction Tool, a system created to support information processing, communications, and medical records for the RADV audit.
NewWave immediately stepped in to stabilize the legacy platform and eliminate performance issues. After our engineers finished system tuning, CDAT was able to manage over 2,000 submissions in a 24-hour period, (a 500% gain from the previous 400 submissions a day!) but our team knew we could do more for RADV.
Transforming RADV with Agile Cloud Migration
Designing Solutions for Future Needs: After securing and stabilizing CDAT, NewWave proposed a custom solution to modernize RADV even further by completely transitioning all infrastructure to Microsoft Azure in the cloud. Our team of architects are experts at cloud migration and redesigning applications as cloud-native – which is exactly what NewWave provided to RADV.
At NewWave, we are continually working on creating and delivering customized, innovative solutions, and Platforms as-a-Service (Paas) for our customer.
Driving Productivity through Human-Centered Design
The Central Data Abstraction Tool (CDAT) is used to facilitate the RADV process by generating and tracking medical record requests, tracing collaboration between coders, and providing the ability for final abstraction data to be extracted for even further analysis.
Human-Centered Design: While the cloud migration process was underway, our team started working on standing up brand new Azure virtual machine (VM) systems to support a full UI redesign of CDAT to improve productivity and efficiency.
At NewWave, we value fairness, accountability, and quality. As a leading systems integrator, we believe it’s our job to deliver advanced, scalable solutions with leading-edge technologies.
For us, it’s more than the solution in itself: It’s about the process of creating a better path forward for the future, protecting Medicare beneficiaries, and creating infrastructure to reduce fraud, waste, and abuse like never before.
Deep Dive into RADV
In 2017, Director of Health Care for the U.S. Government Accountability Office, James Cosgrove, estimated improper claims to the Medicare Advantage program in the prior year alone amounted to 10 percent of the total, or $16.2 billion. Other credible estimates for the entire Medicare system put the number at around $60 billion of invalid claims paid annually.