HHS- Operated Risk Adjustment Data Validdation (H-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:
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). Benefit Years 2015 and 2016 are pilot / beta test years; data validation activities will take place, however appeals and payment adjustments will not occur.
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 H-RADV include:
- 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
Meeting your H-RADV Needs:
- May: Sample Selection by CMS
- June through January: Initial Validation Audit (IVA) Conducted
- Planning Call
- Re-Identification of Sample
- Demographic / Enrollment Validation
- Health Status (Medical Record) Validation
- Reporting Findings
- January through April: Secondary Validation Audit (SVA) Conducted
- Following May: Error Estimation Released
Attest has been conducting H-RADV Initial Validation Audits since the inception of the program in 2015. Attest continues to be the largest IVA firm conducting the most audits (over 170 HIOS IDs).
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.
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™.