Commercial Risk Adjustment Data Validation Support: Initial Validation Audit (IVA) Services
Altegra Health ACA RADV Services Address All CMS Audit Variables and Improve Future Risk Scores
The first year of Commercial risk adjustment has ended and now is the time to select an audit firm to meet new ACA RADV Initial Validation Audit (IVA) requirements. Altegra Health is one of the few partners with fully trained and experienced staff to support all aspects of Affordable Care Act Risk Adjustment Data Validation (ACA-RADV) Initial Validation Audit (IVA) requirements.
The ACA-RADV audits differs substantially from Medicare Advantage (MA) RADV audits and Altegra Health has invested significant resources in understanding ACA data submission as well as the U.S. Department of Health & Human Services’ (HHS) method for calculating risk scores and reinsurance payments.
Our Initial Validation Audit (IVA) services address all levels of detail and documentation needed in a sound risk adjustment strategy. Our demonstrated experience with Medicare Advantage RADV, provider claim data audit and experienced certified coder recruiting helps us navigate the complex process and data relationships extending from medical records and billing/practice management systems all the way through claims clearinghouse and claims adjudication systems. Additionally, we have the technical know-how and expertise for converting source data to HHS’s EDGE Server XML format.
Let our experienced staff develop customized full audit support based on the IVA services you need.
- Enrollment Validation – Auditors review source documentation for each enrollee and validate date of birth, gender and the plan ID. This includes multiple enrollment periods if applicable and the aggregation and analysis of the original 834 files
- Claims Validation – At minimum, auditors validate that risk adjusting claims were paid for dates of service through the specific metal level plan that corresponds to the enrollment validation. This review identifies unsubmitted risk adjusting diagnoses
- Medical Record Validation – Coders certified by American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) with at least 3 years of experience conduct a true medical record validation audit, comparing EDGE server data to the medical record, validating risk adjusting diagnoses codes by provider and date of service. Our medical record auditors are employees based in the United States with specialized validation audit training
- Supplemental Data Validation – Auditors review risk adjusting supplemental codes, assuring they are supported in the record and linked to the appropriate paid claim. Auditors review home assessments, assuring proper documentation and confirm they are linked to claims data according to HHS. Any EDI supplemental files will be audited by our experienced HIM audit team
- Recalculate the Risk Score/Audit Outcomes – Each enrollee’s risk score will be recalculated based on any errors.
- Inter-rater Review – All errors are reviewed by a senior reviewer with three or more years of experience for 2014-2015 audits and five or more years for the 2016 audit and beyond.
- Support the Secondary Validation Audit (SVA) – Altegra Health will provide the SVA with required elements of the IVA error report, as well as provide all original documentation as required to support initial sub-sample and potential additional sub-sample requests.
- Appeals – Should a partner pursue an appeal of the results, Altegra Health will provide supporting documentation as needed.
- Service Delivery Staffing Model – Securing Altegra Health as your IVA audit partner creates a project management team consisting of a managing director, an engagement manager and a team of subject matter experts in the various areas of healthcare operations including, but not limited to claims data review, medical record documentation, education and training, or the technical skill required to complete the project.