What is IVA in risk adjustment?
What is IVA in risk adjustment?
HHS has the authority to conduct a Risk Adjustment Data Validation Audit (RADV) in the Affordable Care ACT (ACA) market based on the following: CMS requires issuers to hire an independent auditor to perform an Initial Validation Audit (IVA) for those members in the sample they choose.
What is IVA in medical coding?
Initial Validation Audit (IVA) – Auditor.
What is an IVA audit?
An IVA involves a stratified random sample of up to 200 members selected by CMS. The health plan provides enrollment and claims data and the medical records for the 200 members to their IVA entity. MetaStar submits the final audit deliverables in the CMS Audit Tool following issuer approval.
Who performs RADV audits?
The Centers for Medicare and Medicaid Services (CMS) perform RADV audits to validate the accuracy of the HCC (Hierarchical Condition Category) codes submitted by MA (Medicare Advantage) plans for payment.
What does RADV stand for?
Risk Adjustment Data Validation
Centers for Medicare & Medicaid Services Risk Adjustment Data Validation (RADV) Medical Record Checklist and Guidance.
What is a CMS RADV audit?
Simply stated, RADV is a course of action that allows the Centers for Medicare & Medicaid Services (CMS) to perform audits on patients’ medical records to verify diagnosis codes that are tied to hierarchical condition categories (HCCs).
What is HHS RADV?
Risk adjustment data validation ensures payment integrity and accuracy – and it affects what plans are paid. Insurers submit their own data, so HHS-RADV works to verify that the data is accurate and complete based on the risks of their members.
How does a RADV audit work?
RADV audits calculate the accuracy of an MA’s risk adjustment conditions based on beneficiary data. The audits validate inpatient, outpatient, and physician medical records and substantiate retrospective payments, prospectively calculate payments to MA plans, and calculate beneficiaries’ overall risk score.
What are the steps for RADV?
RADV is a year-round process, focused on the following timeline:
- October 1 – April 30: EDGE server data submission.
- January – March: Health plans contract with an initial validation auditor.
- Mid-May – June 30: CMS provides health plans with the selected sample enrollees.
What are HCC codes?
HCCs, or Hierarchical Condition Categories, are sets of medical codes that are linked to specific clinical diagnoses. Since 2004, HCCs have been used by the Centers for Medicare and Medicaid Services (CMS) as part of a risk-adjustment model that identifies individuals with serious acute or chronic conditions.
What are the 3 main risk adjustment models?
In addition to the three major risk adjustment payment models already discussed, there are additional models that serve unique populations.
- Programs of All-inclusive Care for the Elderly (PACE)
- End-Stage Renal Disease (ESRD)
- Dual Eligible Special Needs Plans (D-SNPs)