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

    • Planning Call

    • Re-Identification of Sample

    • Demographic / Enrollment Data Validation

    • RXC Validation

    • Health Status Data Validation

    • Reporting Findings

    • 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.

 
 
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™

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™