Health plan compliance teams can now access the first AI-enabled comprehensive audit support solution on the market as part of Coder Workbench

Health plans are under greater scrutiny, navigating an increasingly complex regulatory environment. The Centers for Medicare and Medicaid Services (CMS) estimates $4.7 billion will be recovered from Risk Adjustment Data Validation (RADV) audits, including extrapolation, from 2023 through 2032. To help mitigate this risk, Wolters Kluwer Health has introduced the Regulatory Audit Module as part of its Risk Adjustment solution.

The new module is specifically designed to support Medicare Advantage Organizations (MAOs) during regulatory audits. The Regulatory Audit Module leverages clinically trained artificial intelligence (AI) to increase the efficiency and accuracy of risk adjustment auditing, helping reduce repayment liability by identifying an average of 5-7% additional codes.

Going beyond manual auditing and coding limitations

“When we first launched Coder Workbench, we worked closely with our team of experienced clinical risk adjustment coders to deliver a solution that solved true pain points for both the end user and the C-suite,” said Anne Donovan, Vice President and General Manager, Health Language, Wolters Kluwer Health. “We’ve continued to lean on that expertise to develop the Regulatory Audit Module, combining essential industry insight with AI that, consistent with audit guidelines, recommends charts appropriate to submit to achieve higher validation rates and avoid costly penalties. There isn’t another tool on the market designed to help health plans effectively manage these challenges today.”

In the face of a regulatory audit, manual auditing processes leave room for error, data loss or even corruption of data. Further, aggregating thousands of lines of coding data can be overly complex and burdensome, making it nearly impossible to analyze and identify the most appropriate records to submit for a risk adjustment audit through manual methods.

The Regulatory Audit Module is specifically designed to improve the workflow of a risk adjustment regulatory audit and better ensure the best encounters are submitted for higher validation rates to mitigate the impact of extrapolated repayment penalties.

Embedded logic and AI prioritize charts for more strategic regulatory audit submissions

Bypassing manual processes, the Regulatory Audit Module presents the auditor with all relevant data points with links back to the medical record where each diagnosis was identified. The tool then leverages embedded logic and clinically trained AI to assign a confidence score to each hierarchical condition category (HCC), providing coding auditors with a prioritized subset of charts for review. The module improves the efficiency of an audit workflow by at least 25%, allowing the MAO to navigate compressed auditing timelines more easily.

With real-time visibility on coding and submissions, the Regulatory Audit Module offers essential insights from the auditor level up to the C-suite on audit progression and potential financial impacts.

Please visit our website to learn more about the Regulatory Audit Module, powered by the Health Language Coder Workbench.

For more information about Wolters Kluwer, please visit: www.wolterskluwer.com

About Wolters Kluwer

Wolters Kluwer (EURONEXT: WKL) is a global leader in information, software solutions and services for professionals in healthcare; tax and accounting; financial and corporate compliance; legal and regulatory; corporate performance and ESG. We help our customers make critical decisions every day by providing expert solutions that combine deep domain knowledge with technology and services.

Wolters Kluwer reported 2023 annual revenues of €5.6 billion. The group serves customers in over 180 countries, maintains operations in over 40 countries, and employs approximately 21,400 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands.

For more information, visit www.wolterskluwer.com, follow us on LinkedIn, Facebook, YouTube and Instagram.

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