If you are old enough to remember the first risk adjustment validation (RADV) audits—I won’t call you out but I know that there are many of us—you will remember anticipating that list of members like we were waiting either for Christmas or Doomsday.
We had prepared for months, analyzing every bit of data we had in what usually would prove to be fruitless attempts to guess which members CMS would pick. When the list came some of us would go to Happy Hour while others would scratch their heads, wondering how we could have been so wrong.
We had many questions when RADV audits were new, but few answers. Ten years later we are still searching for answers.
Now here comes the initial validation audits (IVAs) and the fun starts again. Not only do we have to validate the diagnoses, we have to review the process from start to finish. HHS has broken it down into three main domains; Enrollment and Demographics validation, Claims validation and Health Status validation. The Demographic, Enrollment and Claims validation process incorporates validating the data submitted to the EDGE server to the claims data stored within the issuer’s source system.
Data elements to be validated for the Enrollment and Demographic validation are:
- Unique Enrollee ID
- Member ID
- Enrollee First and last Name
- Enrollee DOB
- Enrollee gender
- Subscriber Indicator
- Subscriber ID
- Plan ID
- Enrollment Start and End Dates
- Premium Amounts
- Rating Area
Data elements to be validated for the Claims Data Validation elements include:
- Unique Enrollee ID
- Member ID
- Enrollee First and Last Name
- Enrollee DOB
- Enrollee gender
- Bill Type
- Statement Covers From and Through Dates
- Service Code Qualifier
- Service Code
- Service Code Modifier
- Place of Service
- Final Adjudication Status
Data elements to be validated for the Health Status Data Validation is to ensure medical records meets HHS requirements to validate the issuer-submitted data for enrollee risk scores. Certified coders must verify that the providers and services are acceptable to HHS. The following must be validated and compared to what is in the EDGE server:
- Acceptable date of the medical record or claim
- Validate the Bill Type (Medical record source)
- Validate the signature and Credentials of Providers
- Abstract the diagnoses that are documented
Knowing that history is a great teacher, let’s just accept right now that mistakes are going to be made on both sides of the audit. Take a deep breath and do your best….
