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Solution

Audit Services

Optum provides comprehensive solutions and support services to assist health plans in completing various audits established by CMS, HHS and the OIG.

Deep, expertise, flexible options

The Centers for Medicare & Medicaid Services (CMS), Department of Health & Human Services (HHS) and the Office of Inspector General (OIG) are required to audit diagnosis data submitted by health plans. Preparing for and undergoing an audit can be a massive task and we provide support every step of the way.

Audit services include CMS contract-level Risk Adjustment Data Validation (RADV) audits, CMS Improper Payment Measure (IPM) contract-level RADV audits and HHS-ACA RADV audits. Optum will:

  • Analyze data and identify targeted medical records 
  • Retrieve, code and score records  
  • Prioritize records and submit to CMS or HHS 
  • Determine and collect attestations 
  • Report on audit results

We also offer OIG RADV support, including:

  • Same services offered for CMS and CMS IPM contract-level RADV services 
  • Ability to customize services based on OIG audit requests 

Optum also offers Claims Verification services that allows both prospective and retrospective charts to be evaluated for eligibility. Claims Verification is a process to: 

  • Review accuracy of hierarchical condition categories (HCC) submitted by claim data
  • Compare to coding results from Optum Chart Review service

For clients performing a self-audit, we offer internal data validation review services.

Key benefits

Streamlined audit services for all your needs.

Leverage flexible options

Our solutions can be customized to meet your needs.

Engage dedicated support

We offer dedicated project management and a RADV audit team with extensive experience. 

Get client-focused communication

We work with you and your team through the entire engagement.

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