The Affordable Care Act (ACA) led to the creation of the Health Insurance Exchange (HIX) marketplace. As a result, HHS will require that all Qualified Health Plans (QHPs) to be validated by external auditors; hence, the establishment of the HHS Risk Adjustment Data Validation program. The primary goal of this program is to mitigate the impact of adverse selection. HDC has been involved in the development of this program since 2015. With our skilled certified ICD-10 medical coders, we can help ensure that your risk scores are both accurate and defendable.
The validation process will help to identify data errors that affect the risk scores. HDC analyzes demographic and enrollement information and correlates it to issuer source systems. Medical records are reviewed to substantiate Heirchical Condition Categories (HCCs), and a risk adjustment calculation is performed to identify any changes. HHS will use this process to make financial adjustments between plans. This type of risk adjustment model will generate winners and losers, with some plans receiving more, or less, government funds.
The only approach to safe-guarding your bottom line is to engage with a knowledgeable audit firm and begin the process of data examination and validation. By eliminating inaccurate data (and correcting the processes that produce the data), your organization can prepare for a greater level of stability and confidence. HDC is here to help.
For more information on our experience, resources and services, contact: Paul Ackroyd at 717.458.0554 ext 3003 or pjackroyd@hdcdata.com.