The Health Insurance Exchanges RADV Audit Process


November 25, 2015

For health plans (insurers) participating in the Health Insurance Exchanges (HIX), one important aspect of the program is the Risk Adjustment Data Validation (RADV) audit.  RADV audits have existed for several years in the Medicare Advantage program, but there are several important differences in the HIX (“Commercial”) sphere.

While the 2015 Commercial RADV audits were indefinitely delayed and ultimately foregone, HHS has indicated its intention to begin a six-stage data validation program as follows:

  • Sample selection: HHS determines a “statistically sound” sample size of enrollees from each state in which an insurer operates. This sample will cover applicable subpopulations for each issuer, such as enrollees with and without reported RA diagnoses.
  • Initial Aalidation Audit (IVA): Issuers will conduct an independent audit of the risk adjustment data for their sampled enrollees.
    • Insurers must ensure that the auditor performing this review is “reasonably capable,” and free from interest; that the audit is complete; and that the auditor submits information to HHS in the manner and time frame specified by HHS. This auditor must not be involved in the issuer’s current risk adjustment activities.
    • The issuer’s audit should cover: validation of existing HCC diagnoses; capture of new (missing) HCC diagnoses; and validation of demographic information for patients lacking HCC diagnoses.
  • Second Validation Audit (SVA): HHS will retain an independent second validation auditor to verify the accuracy of a sub-sample of the IVA findings.
  • Error estimation: HHS will estimate risk score error rates based upon validation findings.
  • Appeals: Issuers will have opportunity appeal both IVA and SVA findings.
  • Payment adjustment: In a prospective approach, the issuer’s error rate from the prior year will be utilized to adjust the issuer’s average risk score in the current transfer year. HHS reserves the right to adjust payments for issuers who do not follow the validation audit standards.

(follow the link for the complete blog article:  


Categories: Risk Adjustment, HIX
Tags: RADV

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