Risk Adjustment Data Validation (RADV) audits are a critical component of the Affordable Care Act (ACA) Marketplace, ensuring accuracy of risk adjustment data submitted by health plans. These audits help verify validity and reliability of data used to calculate risk adjustment transfers. Operationalizing a RADV audit involves careful planning, resource allocation, and adherence to regulatory requirements.
Through the Wakely National Risk Adjustment Reporting (WNRAR) project, we analyze RADV performance for about 80% of the Health Insurance Oversight System (HIOS) IDs in the market, which gives us a unique opportunity to better understand how plans are managing the RADV process. Although mean failure rates are improving year over year (with validation rates increasing), the structure of the ACA RADV program means that consistent performance alone may not cut it! We have seen instances in which validating—or failing to validate—a single additional condition resulted in significant RADV risk-transfer adjustments.
We are sharing some of the key questions for health plans to ponder as you reflect on your recent initial RADV results.
- Do you have a playbook on RADV?
- Do you have a team that focuses on ACA RADV? Is it structured for success?
- How are you staying ahead of the various changes to the RADV program?
- What is your process to retrieve and escalate medical chart retrieval for the purpose of RADV? (Reminder: Missing charts for auditors result in automatic non-validation)
- How do you assess if your audit is going well and identify priorities given the short timeline for RADV?
- Are you incorporating RADV findings back to your standard risk adjustment operations?
Conclusion
Operationalizing a risk adjustment data validation audit requires strategic planning, collaboration, and ongoing process improvement. To ensure a successful RADV outcome, it’s not enough to just pass along medical records to your Initial Validation Audit (IVA). If you didn’t get the RADV results you were hoping for, it could be a sign that your check engine light is on and it’s time to take a look under the hood!
If you have questions or feedback, please contact Debbie Conboy.
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