Audit Services

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.