The partners you choose to prepare you for the ACA Commercial Risk Adjustment Audit are essential for determining your plan’s risk score and avoiding costly errors. Selecting your Initial Validation Auditor (IVA) is one of the most important aspects of preparing for Commercial Risk ACA RADV. These are 10 insights that should be considered when selecting an IVA firm.

1. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
The partners you choose to prepare you for the ACA Commercial
Risk Adjustment Audit are essential for determining your plan’s
risk score and avoiding costly errors. Selecting your Initial
Validation Auditor (IVA) is one of the most important aspects of
preparing for ACA RADV. These are 10 insights that should be
considered when selecting an IVA firm.

2. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
1. Expect Health Plan and Provider Claim Data Audit Experience.
Experience in working with a health plan and familiarity with provider claims
is essential in choosing your IVA. An auditing firm must be able to analyze
claims data and confirm that claim submissions accurately represent the
services provided to Plan members.

3. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
2. Consider Medical Record Auditing Capabilities.
The auditor must be capable of performing the initial validation audit free of
conflicts of interest. Issuers must attest to the absence of conflicts when they
notify HHS of their auditing firm.

4. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
3. Validate Risk Adjustment Expertise.
Following direction of the Department of Health and Human Services, an IVA
must fully grasp the implications of the Commercial Risk Adjustment Model
and how the score is calculated in order to effectively serve a health plan. To
evaluate the plan’s data, the IVA must be able to break down the risk model
to account for all variables that contribute to the final score.

5. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
4. Insist on Customizable Audit Services.
A one-size-fits-all approach will not work with many health plans. When
evaluating a potential IVA consider how flexible the firm can be with your
needs, budget, and resources.

6. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
5. Seek Comprehensive Audit Services.
While a one-size-fits-all approach will not work, a “one-stop-shop”
partnership will allow you to form a long term partnership with a firm who
can work with you on all levels of the Initial Validation Audit phase. Services
like a readiness evaluation or a mock audit could prove crucial to success of
the risk adjustment process. Be sure to consider whether or not your
potential IVA firm can service all of your needs in the IVA phase.

7. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
6. Verify Independence and Absence of Conflict of Interest.
The medical record review is perhaps the most important component of risk
score substantiation. An IVA with clinical staff and experienced coders can
best serve a health plan because of the knowledge and expertise required to
accurately and appropriately review medical records.

8. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
7. Understand Fee Structure.
If not planned and budgeted for appropriately, the Commercial Risk
Adjustment process can cause health plans to incur significant costs. When
reviewing contracts and proposals from your potential IVA it is important to
understand how they will charge for services.Issuers should understand what
it included and how much each service costs.

9. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
8. Determine Related Experience.
The IVA firms you are considering may have a range of experience, possibly
even in other industries. It is important for health plans to evaluate what
previous experience may be valuable in serving as an IVA. For instance,
Quality Improvement Organization-like (QIO-like) entities can demonstrate
competence in dealing with the particulars and operational requirements that
Commercial Risk Adjustment audit requires.

10. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
9. Assess Ability to Meet Expected Time Frames.
As the various stages of the process take place, your IVA must be able to
comply with established dead- lines in order to prepare for the Second
Validation Audit performed by HHS or face potential penalties.

11. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
10. Verify Coding Accreditations and Certifications.
If an IVA firm is not properly experienced and accredited the potential for
further risk is increased. Audit reviews must be performed by certified
medical coders (AHIMA or AAPC). A senior reviewer must confirm errors
discovered in the risk adjustment process. For 2014 and 2015, a senior
reviewer is defined as a medical coder having three years of experience. For
2016 and beyond, senior reviewers must have five years of medical coding
experience.

12. 10 Insights for Health Plans:
Hiring an Initial Validation Auditor
For more information on Commercial Risk Adjustment visit
www.hce.org/commercial-risk/