commercial radv audit survival guide - cognisight, llc · commercial radv audit survival guide m a...

©2015 Cognisight, LLC

Presented by: Kim Browning, CHRS, PMP, CHC Executive Vice President

Commercial RADV Audit

S u r v i v a l G u i d e

M a y 1 3 , 2 0 1 5


Today’s Agenda 2

Commercial RADV at a Glance

Components

Best Practices

Choosing Best Medical Record

Choosing Best Vendor

o What to Look for

o What to Avoid

Staff Support

Submitting Supplemental Dx

Q & A

Appendices

o IVA Rules

o Sample Stratum

o SVA Scope

o Payment Adjustments

RA

DV

Su

rv

iv

al

Gu

id

e


Commercial RADV at a Glance:____ Why IVAs Are Necessary

Risk adjustments in the commercial market are zero based

o For every winning issuer, there’s a losing issuer

Better risk scores than your competition’s influences a better “transfer payment”

As a result, there is an incentive to game the system

HHS instituted Initial Validation Audits (IVAs) for every issuer, every year as a deterrent to gaming the system

3


Commercial RADV at a Glance:____ Risk Adjustment Data Validation

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Six-stage process proposed to begin in 2015

Sample Selection

Initial Validation Audit (IVA)

Secondary Validation Audit (SVA)

Error Estimation

Appeals

Payment Adjustments

Independent Vendor

HHS

HHS or Designees

HHS or Designees

HHS


Components:____ IVA Services

5

Analytics

o Triage validation

o Missing HCCs

Chart retrieval HCCs

o EMR

o Paper (fax/mail)

o Uploads

Bi-directional review

o Dx verification and new dx capture

Demographic review

o Demographic verification and new dx capture

Quality control (re-review of information)

Status and results reporting

o Status to client

o Reporting to HHS


Best Practices:____ Initial Validation Audits

6

Consider reusing internal analytics, if available

o As long as analytics meet criteria

Reuse as many existing charts as possible

Choose the best medical record analytics identifies—but be willing to pursue alternate charts if the best medical record isn’t successful

Consider onshore coders only

o HIPAA doesn’t protect data outside US


Best Practices:____ IVAs, cont.

7

Experience with issuer enrollment auditing and tying back to ensure vendor has source documentation, when necessary

o More than simply member eligibility

o Verify items that affect risk adjustment payment

o Mass programmatic changes

Determine what can be done now

o Preassemble your team

o Begin set up of SFTP test file exchanges with vendor(s)

o Determine enrollment sources

o Plan out different scenarios

o Anticipate needs for BAAs and third party data release agreements and secure in advance


Best Practices:____ SVA Readiness

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The best SVA defense is a great IVA offense

o Bulletproof the IVA

Be armed with guidelines, coding clinic, and other reference materials

Expect shared learnings

Be timely with additional requests

Respect differences

o New 50 Shades of Grey


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Run Analytics

Find Matching

Claim/ Chart

Review Yes?

Is There a Missed

Dx?

No

Choosing Best Medical Record:____ Missed Diagnosis

Record for IVA

Analytics must o Select eligible provider and procedure code o Weight providers to each to each dx

Obtain Medical

Record(s)


Choosing Best Medical Record:____ Validation

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Medical Record Tied to Claim

Obtain Medical

Record(s) Validate?

Good Medical Record

Yes?

No?

Initiate Alternate

Pursuit

No?

Other Claims

with Dx? Yes?

DOS = Enrollme

nt Period?

Eligible Provider?

Secure Medical Record

Record Pass

Record Fail

Record Fail

Review


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Knowledge and understanding of rules o Has your vendor read, digested, and operationalized rules?

o Can vendor explain how rules are applied to audit scope?

Prior audit experience o Has vendor previously conducted any Medicare or Medicaid risk

adjustment audits?

o How recently have they completed the audit?

o Do they have “bi-directional” audit experience (i.e. capturing missing diagnoses and verifying existing diagnoses)?

Audit staff o Can vendor document their auditors credentials?

o Does vendor outsource any of their work to other firms? • To be expected due to episodic/seasonal nature of the RADV

Choosing Best IVA Vendor:____ What to Look For


12

Quality control efforts o What percent of captured information is re-reviewed?

• Varies between 10–100%, depending on vendor

Reusability o Is vendor willing to re-use prior analytics?

Chart retrieval o Does vendor offer chart retrieval?

• If so, how many charts are they willing to retrieve?

Fee structure o Are there any hidden fees?

o Does vendor support audit through completion of SVA?

o Does vendor charge implementation or reporting fees?

Choosing Best IVA Vendor:____ What to Look For, cont.


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Testing

o As part of your selection process, “test” vendor

• Review results and compare vendors

Process improvement

o After audit completion, will vendor have provided info to help issuer address any risk points?

o Does vendor understand demographic portion of IVA and have experience in enrollment auditing?

• Can be more than one transaction

o Does vendor validate based on coding guidelines?

• Clinical arguments will not stand

Choosing Best IVA Vendor:____ What to Look For, cont.


14

Waiting too long to select your vendor

o Limited number of strong vendors; risk of being left to choose from second tier

General audit versus risk adjustment audit experience

o Risk adjustment audit experience in particular will help IVA vendor be successful

Choosing lowest priced vendor based on price only

o The financial impact of a poorly run IVA isn’t worth the risk

Not asking what’s outsourced

Vendors that can’t execute end-to-end

o Increased risk points if too many components are outsourced

Choosing Best IVA Vendor:____ What to Avoid


Choosing Best IVA Vendor:____ Given the Gift of Time

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Concurrent chart reviews

o Take learnings and apply to risks prior to IVA

Consider internal sample/audit

o Be sure you have the right staff members/level involved

o Preassemble your audit team


Choosing Best IVA Vendor:____ Given the Gift of Time, cont.

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Validation awareness

o Average dx to verify 1.60–2.25

o Validated dx 43–44%

o Invalid dx’s 56–57%

• No documentation found 78–82%

• Invalid codes 10–13%

• Provider/chart mismatch 8%

• Top HCCs

11 Colorectal, breasts (age <50), and prostate

21 Diabetes without complications*

12 Breast ( age 50+) and prostate

82 Drug dependence

9 Lung, brain, and other severe cancers*

183–188 Kidney transplant, ESRD, and CKD stages 4 and 5

130 CHF*

20 Diabetes with complications

*HCCs also frequently validated


IVA

SVA

On

Standby

On

Standby

Staff Support____ 17

Not Expected

Not Expected

Not Expected


Submitting____ Supplemental Diagnosis

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If conducting chart review for missed dx, must also look for incorrect dx

o Ideally validate what went through in a claim encounter

• If correct dx, no further action required

• If incorrect dx, delete submission via supplemental file

o Ensure encounter was accepted

• If unsure, submit delete

All submissions and deletes must tie to a claim

o When it doesn’t; have a process to research and close the discrepancies

Supplemental files are “in scope” for Risk Adjustment Data Validation (RADV)

File submission

o Tightly follow ICD specs

• Maintain current version

o 16 digit insurance issuer number has to match original claim


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Q&A____

For more information, please contact:

Kim Browning [email protected] 585.662.4215 www.linkedin.com/in/kimbrowning1


Appendix:____ IVA Rules

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All HIX issuers will be audited annually o If operating in multiple states, RADV conducted in each state

200 member sample for ≥1,000 members o 100 member sample for 100–999 members

• Guidance pending for <100

o 2/3 driven by HCC, 1/3 by demographics

o Sample is combined on/off the exchange

Audits are bi-directional o Substantiate submitted HCCs and identify missing HCCs

(including demographic sample)

IVA cannot be HIX risk adjustment vendor

HCC

Demographics


21

Issuers must provide HHS the IVA entity’s name, qualifications, and relationship to issuer

o Deadline to provide above has been suspended indefinitely

Issuers cannot waive obtaining an IVA

Data pulled from EDGE server used for sample

IVA provides audit outcomes to HHS

o Not to the issuer

o Not expected to be via EDGE server

Appendix:____ IVA Rules, cont.


22

IVA entity shall be capable of performing audit and ensuring accuracy of risk adjustments in accordance with standards

Able to complete IVA and submitted IVA findings to HHS in manner and timeframe specified by HHS

Free of conflicts of interest

Must use CCS’, CPCs, or RHITs

For every incorrect HCC, a secondary review has to be conducted by a senior person

Appendix:____ IVA Rules, cont.


Appendix:___ Sample Stratum

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1–3 low, medium, high adults with at least 1 HCC

1–3 low, medium, high children with at least 1 HCC

1–3 low, medium, high infants with at least 1 HCC

10 demographic sample

Remember, all stratum have to also be audited for missing HCCs


Appendix:___ SVA Scope

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SVA will be done by HHS or designated entity

o Will be a subsample of the IVR unless the difference between the samples is too large

• If so, a larger sub-sample will be drawn

o HHS considering a pair-wise evaluation to establish a statistical evaluation between the IVA and SVA

o HHS is evaluating ways to expedite the SVA process

o 95% Inter Rater Reliability (IRR)


Appendix:___ Payment Adjustments

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Safe harbor for Benefit Years 2014 and 2015

Subject to

o Fraud, Waste, and Abuse Act

o False Claims Act

commercial radv audit survival guide - cognisight, llc · commercial radv audit survival guide m a...

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