RISE National 2025 Rewind: Recommendations for Improving Compliance
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Now that RISE National 2025 has concluded, it’s time to recharge and reflect.
The saying “the only constant is change” was appropriate to summarize the conference, as recent priorities have placed a new emphasis on healthcare spending and changed the keynote address at the last minute.
With that in mind, let’s break down the big talking points from RISE National 2025 and how health plans can be prepared to meet and exceed expectations in a stricter regulatory landscape.
RISE National 2025 Recap
Cost savings on government spending have been a key issue since January. This goes hand-in-hand with the 2024 report from the Office of Inspector General (OIG) on the billions spent in overpayments to Medicare Advantage plans based on unsupported diagnoses from enrollees’ in-home health assessments (IHAs) and chart reviews linked to health risk assessments (HRAs).
Jeffrey Grant, former director of the Centers for Medicare & Medicaid Services (CMS), was added as the keynote speaker for this year’s conference at the last minute due to a recent Executive Order that prevented the OIG and Department of Justice (DOJ) from attending or speaking virtually. He noted that CMS is likely to have an outsized role in healthcare policy in the future.
With Dr. Mehmet Oz’s, better known as Dr. Oz, confirmation hearings currently underway, he’s likely to be confirmed as the next Secretary of the CMS and will work closely with Health and Human Services Secretary Robert F. Kennedy on “Make America Healthy Again” initiatives.
However, as of March 13, 2025, no healthcare statutory requirements had been brought to Congress. This means any potential litigation or changes to the Affordable Care Act, Make America Healthy Again, or Medicare for All will need to be presented soon if they want to get something passed in the first session of the House of Representatives. If not, these issues will likely be drawn into a two-session debate.
In the meantime, it can be safe to assume that health plans will have more eyes on them to ensure overpayments and wasteful spending are kept to a minimum.
Why is OIG focusing on HRAs?
In October 2024, OIG released a report on the questionable use of HRAs and chart reviews by MA plans to drive up payments to plans. MA plans receive higher risk adjustment payments from CMS for sicker members, which helps ensure that plans receive proper payments to cover higher-cost care. However, unsupported medical diagnoses on the member record can lead to CMS inadvertently spending billions of dollars in inflated risk adjustment payments.
In the report, OIG found that an estimated $7.5 billion in risk adjustment payments were issued in 2023 based on diagnoses reported only on members’ in-home HRAs and HRA-linked chart reviews and not on any other 2022 service records.
This means that the lack of follow-up visits, tests, and procedures for these diagnoses raises concerns that either:
- The diagnoses are incorrect, creating an improper payment, or
- Plan members are not receiving the care they need to properly manage chronic conditions
HRAs or IHAs comprised almost two-thirds of the risk adjustment payments in 2023. IHAs, in particular, are vulnerable to misuse because they’re often administered by an MA plan or a third-party vendor instead of the member’s healthcare provider. This puts added pressure on health plans to validate their submissions.
How health plans can prepare for RADV audits
Scrutiny over wasteful spending will continue following OIG’s report on top of an already intensifying regulatory landscape. For health plans thinking about RADV audits, it’s not a matter of “if”; it’s “when.”
MA plans must be prepared for a RADV audit at any time, as failing to validate even a small percentage of diagnoses can lead to significant financial consequences. Plus, it’s not only your finances at stake; it’s also your health plan’s reputation. Below are key steps your organization can take now to ensure audit readiness.
1. Create an internal compliance program and coding team
Every health plan needs a compliance program and a dedicated coding team because CMS expects plans to actively look for and fix coding errors. While the goal is to prevent incorrect codes from being used, it’s up to the health plan to go back and ensure accuracy.
2. Directly engage with providers
Working closely with providers can ensure accurate and complete documentation before submitting claims for risk adjustment. Health plans can implement the following provider engagement strategies:
- Standardize data collection
- Conduct regular data accuracy education sessions
- Provide feedback to providers from internal audits
- Leverage digital tools for data accuracy
3. Use technology that helps in the audit process
Collecting, cleaning, managing, and maintaining data no longer needs to be a manual process. With the right technology tools, health plans can better manage their risk adjustment data.
Some of the solutions that can help health plans improve audit readiness include:
Artificial intelligence (AI), machine learning (ML), and natural language processing (NLP): AI and ML algorithms can help identify unusual patterns or abnormalities in data submissions to flag any potential inaccuracies. Also, NLP can help automate the review of collected provider documentation, such as medical record reviews, to assist in validating diagnosis codes. However, OIG and DOJ see relying entirely on AI, ML, and NLP for reviewing medical records as a potential risk for unchecked errors. This is why health plans need to maintain human oversight while leveraging AI tools.
Advanced data analytics: Health plans can partner with providers in their network to connect data analytics solutions with providers’ existing systems, such as their EHR. The analytics can then support accurate documentation for their provider by analyzing data as it’s entered, avoiding submission of unsupported conditions.
4. Choose the right technology partner
MA plans looking to strengthen their compliance and data management program for RADV audits may lack the in-house expertise or resources to do so. This is why partnering with the right technology partner can help act as an extra set of hands to support your initiatives.
When looking for a technology partner, consider the following:
- Risk adjustment experience and expertise
- Compliance and data security practices
- Integration capabilities into your existing systems
- Ongoing customer support
- Ability to scale to meet your needs
What’s next following RISE National 2025?
As we look ahead, RISE National 2025 made one thing clear: compliance isn’t just about following the regulations – it’s about what’s next. With increased scrutiny of MA plans and risk adjustment audits, proactive strategies will be essential.
Health plans can navigate the evolving regulatory landscape by investing in strong compliance programs, deepening provider relationships, and using software that helps ensure reporting compliance and audit readiness. The road ahead may be challenging, but the right approach can lead to greater efficiency and better healthcare outcomes.
If you didn’t have a chance to stop by the Inovalon booth at RISE, contact us today to schedule time with a representative and explore how Inovalon can help your plan be RADV ready.
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