Data validation audits can carry a significant financial risk. For audits conducted by the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS), the rate of unsupported Hierarchical Condition Categories (HCCs) determined by any such audit sample may be considered by CMS and HHS to be a representation of the error rate in your overall population, and this could impact you significantly. Just selecting a single unsupported condition for a RADV Audit sample can have an immense financial impact.
Risk Mitigator (formerly Valid8) was designed to expose risks such as these, so the associated claims and submissions data can be adjusted appropriately. As the HCCs and risk adjustment models differ in each government program, Veradigm Payer Analytics provides versions of Risk Mitigator specific to Affordable Care Act (ACA) and Medicare Advantage (MA) populations.
Risk Mitigator estimates the probability that it has identified a bona fide coding risk and then quantifies the financial exposure on an HCC-specific basis, as well as a program extrapolation basis. Just as Risk Adjustment Analytics supports your revenue goals in the identification of persisting and suspecting conditions, Risk Mitigator highlights those HCCs at potential risk for RADV Audit. Taken together, Risk Adjustment Analytics and Risk Mitigator ensure that you safely get your risk-adjusted fair share while also managing your audit risk.
Veradigm has leveraged data mining and our collective experience with data validation exercises to identify conditions that are less apt to be coded correctly and more susceptible to being audited. Risk Mitigator also identifies those providers and groups whose poor documentation habits are putting your plan at greater risk.
Learn More About Veradigm’s Risk Mitigator for RADV Risk Mitigation
Risk Mitigator is the “voice of caution” in Veradigm’s product suite for health plans and payers, charged with reducing the likelihood risk-bearing entities get significantly impacted because of a Data Validation Audit.