For health plans participating in the Affordable Care Act Health Insurance Marketplace, U.S. Department of Health and Human Services Risk Adjustment Data Validation (HHS-RADV) reviews are high stakes. Diagnosis data, prescription drug information, enrollment records, and strict requirements from the Centers for Medicare & Medicaid (CMS) all contribute to a complex process. The outcomes of that process can directly affect ranking and reputation, compliance outcomes, and financial bottom lines.
That’s why many Health Insurance Marketplace® health plans turn to experienced Initial Validation Audit (IVA) partners like MetaStar.
As a trusted independent third-party IVA auditor, MetaStar helps health plans navigate the highly technical HHS-RADV process with confidence. Whether it’s validating demographic and prescription drug data, reviewing medical record documentation, or helping plans decipher technical requirements, MetaStar’s experienced auditors guide organizations through each stage of the audit process.
“We know how stressful [the HHS-RADV process] can be,” said Ross Gatzke, Practice Leader for URAC and IVA, in MetaStar’s Performance Measurement Department. “So we try to do our best to alleviate as much of that burden as possible.”
Under the commercial risk adjustment program, CMS redistributes funds based on risk scores. Health plans with lower-risk member populations provide funds to plans covering higher-risk members. Because those risk profiles depend heavily on substantial amounts of medical data, CMS requires plans to undergo an HHS-RADV review. During this review, CMS examines a sample of enrollee records to calculate a plan’s total risk score. The score is then compared against similar plans in the region. Based on those calculations, plans may receive or owe funds through the risk adjustment process.
“Health plans are compensated based upon their enrollee risk scores,” explained Gatzke.
Before data can be submitted to CMS, the plan must undergo an IVA. The audit must be performed by an independent third party such as MetaStar. “When we validate data, we’re saying the information the health plan submitted to CMS is accurate and complete,” said Gatzke.
The IVA process involves three major components: Demographics and Enrollment (D&E), Prescription Drug Validation (RXC), and Health Status Data Validation (HSDV), also known as medical record review.
The IVA uses a sample of enrollee records out of the two hundred identified for CMS submission. MetaStar’s auditors carefully compare submitted data against source documentation and systems. For D&E and RXC, auditors compare submission data to screenshots taken from multiple original sources. These sources can include the plan’s enrollee database, a medical or prescription claims system, a pharmacy benefits manager (PBM), clearinghouses, and others.
Even seemingly small discrepancies can create problems during submission and review. In one example, Gatzke described a system setup issue that rounded all enrollee premium amounts, causing every value to be slightly incorrect.
HSDV, or medical record review, is often the most detailed and time-intensive part of the IVA process.
“The goal for the medical record review is to validate all of the ICD-10 diagnosis codes that were submitted by the plan for that enrollee,” said Gatzke.
Certified medical coders review patient charts and translate ICD-10 diagnosis codes into Hierarchical Condition Categories (HCCs). CMS assigns each HCC a risk level, which contributes to a member’s risk score. To validate the HCC, coders must locate a qualifying encounter where an eligible provider documented and addressed the condition during the benefit year.
“It’s only the documentation in this provider’s note that is reviewed,” Gatzke explained, stressing the importance of appropriate provider documentation. Labs, imaging, referrals, and orders may support the clinical picture, but they do not independently validate a diagnosis unless the provider documents them in the visit note.
In some cases, MetaStar identifies coding or documentation issues where a provider billed or coded for a condition but did not adequately address it in the encounter note. “User error, system setup issues, and documentation errors are common,” said Gatzke, but they are usually due to human error and not purposeful fraud.
While audits often seem punitive, the MetaStar’s IVA process focuses on ensuring customers submit the most reliable data.
MetaStar’s auditors regularly work directly with customers to answer coding questions, discuss nuanced scenarios, and help organizations navigate complicated requirements with confidence.
“We’re good at continuously monitoring progress and ensuring everyone is on the same page,” Gatzke said. MetaStar’s SOC 2 Type 2®-certified web portal plays a large role in that. The IVA application inside the portal is one of the most robust built by MetaStar. Reports and timelines within the application can show customers, down to the specific record, how much of the audit has been completed. MetaStar’s Department of Information Technology can also create customized activities and reports quickly based on a client’s specific needs.
MetaStar’s team works proactively throughout the process. Their quick turnaround times help plans avoid last-minute issues and submission bottlenecks.
“When we complete our review, we provide details on any questions or errors we found,” explained Gatzke. “The health plan has as many chances as possible to correct any errors.”
“We want to give them the opportunity to turn over every stone to allow them to submit all information because we do understand how important the results are,” he added.
Health plans choose MetaStar not only for technical expertise but also for responsiveness, reliability, and partnership throughout the IVA process.
MetaStar’s many advantages include:
Most importantly, Gatzke concluded, “We want the customer to feel valued.”
Reliable healthcare systems depend on reliable data. For health plans navigating HHS-RADV requirements, the IVA process can be stressful, strenuous, and vexing. MetaStar has decades of healthcare quality expertise, experienced auditors, and a collaborative customer-focused approach. IVA season is starting soon. Make sure you get the experienced, responsive partner that can help you navigate the IVA process with confidence and clarity.
For more information or to begin the IVA contracting process with MetaStar, contact Manny Martin, Vice President of Performance Management, by phone at (608) 441-8264 or by email at mmartin@metastar.com.
Ross Gatzke, Practice Leader for URAC and IVA, has been at MetaStar for 11 years. Ross takes pride in providing efficient, proactive customer service. He says the healthcare data validation and auditing work isn’t glamorous, but it’s satisfying and fulfilling—even if his parents aren’t exactly sure what he does.
Kate Schultz, a freelance writer for MetaStar, is proud to have completed 21 blog posts for the organization. Her varied and engaging interview subjects have taught her a lot about healthcare quality improvement. She might even be able to explain to Ross’s parents what he does.