Claim and Diagnosis Validation Audits

Risk adjustment is a methodology used to assess a person’s health status based on demographic data and overall medical conditions. Many consider risk adjustment data as an essential mechanism for health insurance programs to account for the overall health and expected medical costs of individuals enrolled in a health plan. It is used as the basis for reimbursement by CMS, states, and for health care provider programs.

For years, CMS has conducted validations on the data submitted by health plans for Medicare members to ensure reimbursement is commensurate with the membership and conditions being served by the health plan.  Most recently, as a result of the Affordable Care Act (ACA), HHS-RADV reviews were introduced to validate the data used for the payment transfer determinations for commercial insurers in the small group and Exchange markets.  Medicaid plans in some states are also now starting to request similar validations.

The key components to these reviews are validating the member demographic information and validating that the coded conditions are treated on an ongoing basis. In some cases, validating prescribed medications may be a component of the review as well. The medical conditions for members are obtained through diagnoses submitted on claims and encounters by treating providers.

Meeting Your Audit Needs:

For several years Attest has conducted HHS-RADV audits on behalf of commercial payers.  This has resulted in a substantial experience in validating member demographic data and ensuring medical record documentation supports the conditions billed on claims data. Through our reviews, this data was then translated into the corresponding Hierarchical Condition Categories (HCCs), and ultimately into a member’s risk score.

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 will create an audit methodology to conform to the audit requirements for your program or customize risk adjustment or medical record coding audits to meet your organization’s needs.  Contact us today for more information!