ACA RADV- Hiring an Initial Validation Auditor

The partners you choose to prepare you for the ACA Commercial Risk Adjustment Audit are essential for determining your plan’s risk score and avoiding costly errors. Selecting your Initial Validation Auditor (IVA) is one of the most important aspects of preparing for ACA RADV. These are 10 insights that should be considered when selecting an IVA firm.

1. Expect Health Plan and Provider Claim Data Audit Experience.

Experience in working with a health plan and familiarity with provider claims is essential in choosing your IVA. An auditing firm must be able to analyze claims data and confirm that claim submissions accurately represent the services provided to Plan members.

2. Consider Medical Record Auditing Capabilities.

The auditor must be capable of performing the initial validation audit free of conflicts of interest. Issuers must attest to the absence of conflicts when they notify HHS of their auditing firm.

3. Validate Risk Adjustment Expertise.

Following direction of the Department of Health and Human Services, an IVA must fully grasp the implications of the Commercial Risk Adjustment Model and how the score is calculated in order to effectively serve a health plan. To evaluate the plan’s data, the IVA must be able to break down the risk model to account for all variables that contribute to the final score.

4. Insist on Customizable Audit Services.

A one-size-fits-all approach will not work with many health plans. When evaluating a potential IVA consider how flexible the firm can be with your needs, budget, and resources.

5. Seek Comprehensive Audit Services.

While a one-size-fits-all approach will not work, a “one-stop-shop” partnership will allow you to form a long term partnership with a firm who can work with you on all levels of the Initial Validation Audit phase. Services like a readiness evaluation or a mock audit could prove crucial to success of the risk adjustment process. Be sure to consider whether or not your potential IVA firm can service all of your needs in the IVA phase.

6. Verify Independence and Absence of Conflict of Interest.

The medical record review is perhaps the most important component of risk score substantiation. An IVA with clinical staff and experienced coders can best serve a health plan because of the knowledge and expertise required to accurately and appropriately review medical records.

7. Understand Fee Structure.

If not planned and budgeted for appropriately, the Commercial Risk Adjustment process can cause health plans to incur significant costs. When reviewing contracts and proposals from your potential IVA it is important to understand how they will charge for services.Issuers should understand what it included and how much each service costs.

8. Determine Related Experience.

The IVA firms you are considering may have a range of experience, possibly even in other industries. It is important for health plans to evaluate what previous experience may be valuable in serving as an IVA. For instance, Quality Improvement Organization-like (QIO-like) entities can demonstrate competence in dealing with the particulars and operational requirements that Commercial Risk Adjustment audit requires.

9. Assess Ability to Meet Expected Time Frames.

As the various stages of the process take place, your IVA must be able to comply with established dead- lines in order to prepare for the Second Validation Audit performed by HHS or face potential penalties.

10. Verify Coding Accreditations and Certifications.

If an IVA firm is not properly experienced and accredited the potential for further risk is increased. Audit reviews must be performed by certified medical coders (AHIMA or AAPC). A senior reviewer must confirm errors discovered in the risk adjustment process. For 2015, a senior reviewer is defined as a medical coder having three years of experience. For 2016 and beyond, senior reviewers must have five years of medical coding
experience.