Risk Adjustment Data Validation, RADV

Take Action before May 9, 2016

Commercial plans offering small group or individual products must contract with an audit firm to perform Risk Adjustment Data Validation (RADV) and notify CMS of that selection by May 9, 2016.

As part of the Affordable Care Act (ACA) a new audit requirement was introduced for commercial health plans - Risk Adjustment Data Validation Audits (RADV). This new requirement affects all commercial insurers that offer individual and small group policies. RADV is not limited to plans that are on the Exchanges, all health plans on and off the Exchanges are required to participate in RADV in 2016.

RADV is conducted on a sample of 200 members per insurer per state (reduced sample size for plans with less than 4,000 members). Once CMS provides the sample list to the health plan (approximately July 1, 2016), you are responsible for compiling all of the demographic, enrollment and medical record data to support the overall risk score for each member. Submitted documentation is reviewed by Attest to validate the members’ risk scores are accurate. In addition to the experience brought by certified coders, we also have a board certified Medical Director and Registered Nurses supporting the project.

Risk Adjustment Highlights_updated.pdf

We believe that medical expertise is vital to understand highly complex cases and ensure the only true errors are reported.

Throughout this process, we will communicate our findings to you and allow you the opportunity to verify that all pertinent information is submitted prior to making a final decision. We employ a collaborative process and are committed to maintaining ongoing communication with you.

Attest would be proud to perform the Risk Adjustment Data Validation (RADV) Audit for your plan. Our goal is to make your RADV audit as smooth as possible by leveraging our experience of providing quality, collaboration and transparency. We evaluate the accuracy of diagnostic and service events on over 7,000 charts each year. This vast experience means we can review your files quickly and efficiently to make your RADV a successful experience. After conducting countless audits over the past 20 years, we have never missed a reporting deadline and our references speak for themselves:

Risk Adjustment Data Validation Information

Due to the delay of the RADV for 2014 benefit year, issuers and auditors will only have one preliminary testing year in 2016 for 2015 benefit year data, instead of two years to implement and test the RADV program. In keeping with the original schedule, risk adjustment payments and charges will be adjusted in 2018 for 2016 benefit year data.

As of January 1, 2014, health plans can no longer deny coverage or charge higher premiums based on pre-existing conditions to make it easier for people to gain coverage at a reasonable price. The Affordable Care Act’s risk adjustment program is intended to help protect you against the negative effects of adverse selection and to stabilize premiums as illustrated below. In summary, risk adjustment will:

    • Reduce the impact of any adverse selection
    • Transfer funds from plans with lower-risk enrollees to plans with higher-risk enrollees
    • Encourage insurers to compete based on the value and efficiency of their plan
    • Help stabilize premiums
The only Plans not subject to the Risk Adjustment system – and Audit:
    · Plans that were renewed prior to January 1, 2014
    · Student health plans
    · Private plans that contract with Medicare or Medicaid
    · Self-insured plans
    · Plans that are not subject to the ACA’s market reforms (such as guaranteed issue, single risk pools, and essential health benefits)

    CMS will not enforce the 2015 BY HHS-RADV audit requirement for:
    · Issuers that have no RA-covered plans in the individual and small group markets in the 2016 benefit year; and
    · Issuers with 500 or fewer billable member months in the individual and small group markets combined statewide as of the February 2, 2016 data submission for the 2015 benefit year Risk Adjustment. (Issuers may still participate if they desire.)

Learn more about CMS’s Requirements

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Please contact us if you would like additional information or a proposal on any of the services we provide.

Attest Health Care Advisors is an NCQA-licensed organization authorized to conduct HEDIS® audits. Only an NCQA-licensed organization is authorized to conduct HEDIS Compliance Audits™.