The U.S. Department of Health and Human Services (HHS) was supposed to send the first Affordable Care Act (ACA) risk adjustment data validation (RADV) audit sample to issuers this summer, but, as often happens in government, there was a delay.
Despite the delay, HHS announced it intended to move forward with the “test” ACA RADV Initial Validation Audits (IVA) in the summer and fall of 2016, which means the deadline to select an IVA vendor to assist with the test audit is just around the corner.
An IVA vendor will examine source documentation and recalculate risk scores to establish an error rate. A subset of the IVA results will be validated by a Secondary Validation Audit performed by HHS or its designee. Before the actual IVA, however, issuers can prepare by conducting a “mock” or simulated audit to expose and correct audit vulnerabilities prior to the IVA auditor’s review. Here’s how:
1. Compile chart review data and risk scores. The HHS began sending ACA issuers Interim Risk Score Reports to validate risk scores based on previously submitted data. This report, combined with issuer’s own internal medical record reviews of ACA-plan members to identify risk adjusting conditions, can serve as the foundation for the IVA simulation.
2. Review claims and audit data. Using these supplemental chart review projects, issuers can conduct a simulated full validation audit on a subset of the charts. This mock audit should include verifying enrollment and claims data in its original format before it is transformed for submission to CMS over the EDGE server.
3. Fix risk score errors. Ensure the necessary systems are in place to identify and research the cause for any variation in risk scores between the HHS report and your calculation. Using these reports to conduct pre-audit reviews and correct the cause for any risk score variations could prevent potential RADV errors when the IVA occurs.
If you didn’t select an IVA vendor yet, remember the firm must have no financial conflicts of interest, but should be staffed with qualified coders and have plenty of experience with EDGE servers and ACA risk adjustment. With the right preparation, the first actual ACA-RADV IVA should contain no surprises – except maybe another regulatory delay.