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Audit Services

Optum provides comprehensive data validation and support services to health plans for CMS and HHS risk adjustment data validation (RADV) audits.

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Deep expertise, flexible options

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

CMS- or HHS-targeted risk adjustment data validation:

  • 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

National sample RADV audit support: 

  • Optional service is a subset of the CMS- or HHS-targeted RADV service
  • Includes same services offered for the CMS- or HHS-targeted RADV service listed above 

Key benefits

  • Flexible options based on client needs
  • Dedicated project management and RADV audit team
  • Client-focused and communicative throughout engagement

Other audit services

Optum Claims Verification service is a process to: 

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

The service allows both prospective and retrospective charts to be evaluated for eligibility.  

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

See how Optum can drive better risk and quality outcomes for members, health plans and providers