HHS-Risk Adjustment Data Validation (HHS-RADV)
As part of the Affordable Care Act (ACA) a new audit requirement was introduced for qualified health plans: Risk Adjustment Data Validation (RADV) Audits. This impacts all commercial insurers on and off the Exchange offering individual and/or small group policies.
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. To create a fair playing field for Insurers (Issuers), RADV is intended to:
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 Secretary of Health and Human Services (HHS) has designated Center for Medicaid and Medicare Services (CMS) to implement the HHS-RADV program (H-RADV).
RADV consists of a two-tier approach with Issuers contracting with an independent organization, such as Attest, to perform an Initial Validation Audit (IVA) and CMS contracting with an organization to perform a Secondary Validation Audit (SVA).
Key activities of HHS-RADV include:
May: Sample Selection by CMS
June through January: Initial Validation Audit (IVA) Conducted
Re-Identification of Sample
Demographic / Enrollment Data Validation
Health Status Data Validation
January through April: Secondary Validation Audit (SVA) Conducted
Mid-June: Issuer and enrollee-level results released
Meeting your HHS-RADV Needs
Attest has been conducting HHS-RADV Initial Validation Audits since the inception of the program in 2015. Approximately 1/3 of the risk adjustment covered plans who participated in the 2017 benefit year HHS-RADV were audited by Attest.
The hallmark of Attest’s approach is transparency in everything we do and we strongly believe in a collaborative process. We are committed to involving you throughout the process and maintaining ongoing communication. We will share findings throughout the audit process and provide a feedback loop where you will have the “opportunity to cure” concerns or errors.
Attest’s IVA audit methodology conforms to the HHS / CMS final rule for Risk Adjustment Data Validation.