ACA HHS-Operated Risk Adjustment Data Validation...

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ACA HHS-Operated Risk Adjustment Data Validation (HHS-RADV)

Audit Procedures

December 16, 2015

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Health Insurance Marketplace Program Training Series

https://www.regtap.info/


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Session Guidelines Intended Audience Session Purpose HHS-RADV o Authority ooooo

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Overview Timeline IVA Process Documents Demographic & Enrollment Validation Health Status Data Validation Medical Records Intake Medical Record Review & Diagnosis Abstraction

Session Agenda

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Next Steps Questions Resources and Closing Remarks



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This is a 90-minute webinar session For questions regarding content, please submit inquiries to REGTAP at https://www.REGTAP.info/. For questions regarding logistics and registration, please contact the Registrar at: (800) 257-9520. Frequently Asked Questions (FAQs) will be posted on REGTAP in the coming weeks.

Session Guidelines

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Issuers of Marketplace and non-Marketplace individual and small group plans, in states where the Department of Health and Human Services (HHS) operates the Risk Adjustment (RA) program*. Potential Initial Validation Audit (IVA) Entities. Third Party Administrators (TPA) and support vendors. Second Validation Audit (SVA) Entities.

* This includes state-based, Federally-facilitated, and Small Business Health Options Programs (SHOP). Massachusetts is the only state running their own RA program in 2015

Intended Audience

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Provide an overview of the HHS-RADV Initial Validation Audit (IVA) processes including descriptions of data, records and reports needed to perform the audit. Provide validation process details for enrollment and demographics and as well as describe validations required for the health status data validation process.

Session Purpose

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HHS-RADV Overview

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Section 1343 of the Affordable Care Act (ACA) establishes a permanent Risk Adjustment (RA) program which is intended to provide payments to health insurance issuers that attract higher-risk populations. The Premium Stabilization Final Rule requires states, or HHS on behalf of states, to validate a statistically valid sample of data for all issuers that submit for risk adjustment every year and provide an appeals process. The rule allows states, or HHS on behalf of states, to adjust average actuarial risk for each plan based on the error rate found in validation and adjust payments and charges based on the changes to average actuarial risk.

HHS-RADV Authority

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• The Secretary of HHS has designated CMS to implement the HHS-RADV program in accordance with the following regulations: o

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45 CFR §153.350 45 CFR §153.620 45 CFR §153.630 Premium Stabilization Final Rule 2014 Payment Notice Final Rule 2015 Payment Notice Final Rule

HHS-RADV Authority

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Key Components: • CMS selects a statistically valid sample of enrollment and

medical claims data submitted to the issuer’s External Data Gathering Environment (EDGE) server.

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Data validation of the selected sample is conducted by an initial validation auditor (IVA Entity) selected by the issuer and approved by CMS. CMS selects a second validation auditor to validate a subsample of the original IVA sample. CMS establishes an issuer-level error rate based on data validation results. CMS applies the error rate to each issuer’s RA covered plan average liability risk score (PLRS) to produce an error estimate.

HHS-RADV Overview

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Key Components (continued): •

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CMS provides an HHS-RADV appeals process for issuers. CMS adjusts the PLRS for issuer’s risk adjustment covered plans based on errors discovered as a result of data validation.

While data validation activities will occur for benefit year 2015 data, 2015 is an HHS-RADV pilot year; therefore, HHS-RADV appeals and payment adjustments will not occur.

HHS-RADV Overview (continued)

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HHS-RADV Timeline

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HHS-RADV Timeline

Date Description Fall 2015 HHS-RADV trainings begin December 31, 2015 2015 benefit year ends Winter 2015 through Spring 2016 Issuers select IVA Entity Spring 2016 Issuers submit IVA Entity to CMS for approval April 30, 2016 2015 data submission deadline

Summer 2016 through Fall 2016 CMS generates sample of enrollees and their medical claims for each issuer and the IVA is conducted

Fall 2016 through Winter 2017 Second Validation Audit (SVA) is conducted

Winter 2017 Pilot results and lessons learned will be released, including 2015 error rates

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HHS-RADV Initial Validation Audit Process

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HHS-RADV consists of IVA and SVA entities testing a sample of issuers’ enrollees to determine if an error rate is to be applied to the issuer’s plan average risk score(s) based on results of the IVA and SVA. • HHS-RADV Process includes the following six stages:

HHS-RADV IVA Process

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* Processes do not apply to 2015 benefit year data.



Determining a Risk Adjustment Error • An RA error occurs when a discrepancy uncovered in the data validation

audit process results in a change to the enrollee’s risk score. •

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An RA error could result from incorrect demographic data, an unsupported Hierarchical Condition Category (HCC) diagnosis, or a new HCC diagnosis identified during medical record review. An unsupported HCC diagnosis could be the result of missing medical record documentation or medical record documentation that does not reflect the diagnosis. An unsupported HCC diagnosis could result from invalid medical record documentation including includes a record that is not signed by an eligible provider, or a record that does not meet RA data collection standards for the applicable benefit year.


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The issuer provides the IVA Entity with source enrollment documentation. Issuers are responsible for making all necessary documents accessible to the IVA Entity.

The demographics and enrollment review will be used to validate that enrollment data submitted to the EDGE server is the same as the enrollment transactions stored in the issuer system.


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The issuer provides the IVA Entity with source medical record documentation to validate issuer-submitted medical claims and supplemental diagnoses for RA data for each sampled enrollee. Issuers are responsible for making all necessary documents accessible to the IVA Entity. The review of enrollee health status must be conducted by certified medical coders accredited by a nationally recognized accrediting agency such as:

American Health Information Management Association (AHIMA). American Academy of Professional Coders (AAPC).


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If a discrepancy is uncovered in the data validation audit process and results in a change to the enrollee’s risk score it is determined to be a risk adjustment error. A risk adjustment error could result from incorrect demographics data, an unsupported HCC diagnosis, or a new HCC diagnosis identified during the medical record review. If a risk adjustment error is identified, the error must be validated by having a senior reviewer confirm any errors resulting from incorrect demographics data, an unsupported HCC diagnosis, or a new HCC diagnosis that was identified during the medical record review. A “senior reviewer” is a reviewer certified as a medical coder by a nationally recognized accrediting agency who possesses at least five (5) years of experience in medical coding.

For the 2015 benefit year, a senior reviewer may possess three (3) or more years of experience.


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Inter-Rater Reliability (IRR) •

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The initial validation auditor must measure and report to the issuer and CMS its IRR rates among its reviewers specific to the HHS-RADV audit. For the 2015 benefit year the initial validation auditor must meet an IRR rate of 85 percent for the audit. For benefit year 2016 and thereafter, the initial validation auditor must achieve an IRR rate of at least 95 percent. o

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IRR measures the degree of agreement among reviewers. The required IRR rate is the rate at which a senior reviewer’s results for HCCs match the results of another reviewer. If the IRR rate is not met, either additional medical records must be sampled until the required accuracy rate is met or all medical records must be reviewed by a senior reviewer.


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HHS-RADV Documents

Needed for the IVA

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Documents Needed to Conduct the IVA: •

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EDGE server RADV IVA Sample Report The sample report will include the masked unique enrollee IDs for the enrollees in the audit sample, the associated enrollment records and all claims associated with the enrollees in the audit sample. Issuers must match or provide means to match masked enrollees to actual enrollees.

Enrollment Records All American National Standards Institute (ANSI) 834 or other enrollment source documentation used by the issuer for each enrollee in the sample.

Medical Records All medical records, charts, or encounter data associated with claims that were submitted to the EDGE server for each enrollee in the sample.

Original Claims The original claim from the issuer’s proprietary system that was adjudicated and submitted to the EDGE server.

Documents for the IVA

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Enrollment Records: •

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Issuers should provide all enrollment forms associated with the applicable benefit year. Issuers should ensure the most current enrollment information is provided to the IVA Entity.

For example, if the enrollee had changes to name or residency or plan cancellation, it is imperative that the IVA Entity receives the most updated enrollment file.

If an enrollee changes plans within a benefit year, the issuer must provide all enrollment records for the enrollee.


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ANSI 834 or Enrollment Record: •

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The ANSI 834 enrollment record (834) is used to transmit demographics and enrollment data between the Marketplace and issuers and includes all demographics and enrollment data for each enrollee in an issuer’s plans. Though not required of plans outside of the Marketplace, it is recommended that issuers adopt the 834. If an issuer does not use the 834, an issuer-based enrollment form, or other issuer documentation providing equivalent demographics and enrollment information data found on the 834 may be used.


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Medical Record Documentation: •

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Medical Record documentation must originate from the provider of services and align with dates of service for the medical diagnoses and reflect permitted providers and services. For purposes of HHS-RADV, “medical record documentation” means clinical documentation of hospital inpatient, outpatient treatment or professional medical treatment from which enrollee health status is documented and related to accepted RA services that occurred during a specified period of time. Medical record documentation must be generated in the course of a face-to-face or telehealth visit documented and authenticated by a permitted provider. Only medical records for services that resulted in an adjudicated claim that was accepted by the EDGE server will be allowed.


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Original Claim: •

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The EDGE server RADV IVA Sample Report will include all claims associated with the sampled enrollees. Issuers must provide the original claim information from their claims systems from which the EDGE server claims data was derived, for all claims in the sample report. The claim should be the final adjudicated claim only. Issuers should provide the following:

ANSI 837: Standard format used by industry to transmit electronic health care claims. ANSI 835: Electronic Remittance Advice (ERA) format is used to provide electronic claim payment information. If an issuer does not use the ANSI format, an issuer-based claim form, or other issuer documentation providing equivalent claims information found on the 837/835 may be used.


The issuer must provide medical records linked to claims submitted to the EDGE server for the enrollee and provide the medical record and claim to the IVA Entity to perform the IVA.

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HHS-RADV Demographics and Enrollment Validation

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Below is the process for IVA entities to perform the demographic and enrollment validation.

Demographics and Enrollment Validation

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During the demographics and enrollment validation process, IVA entities will need to validate that the enrollment data submitted to the EDGE server matches enrollment data stored within the issuer’s enrollment system. Issuers must link the masked unique enrollee ID from the EDGE server RADV IVA Sample Report to the actual enrollee’s enrollment file. Issuers must provide all enrollment records for each enrollee in the sample. If an enrollee changes plans within a benefit year, the issuer must provide all enrollment records for the enrollee.

Demographics and Enrollment Validation

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The IVA Entity must compare the following eight (8) enrollee factors from the issuer enrollment files to the IVA Sample Report data and document identified discrepancies.

Issuer ID Plan ID (16-digit) Cost-sharing Reduction (CSR), if applicable Rating area Enrollment start and end dates Premium Amount

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Enrollee date of birth Enrollee gender

Demographics and Enrollment Data

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The demographics and enrollment validation process will require the identification of the following three (3) data elements for each enrollee in the sample.

Enrollee Name Subscriber Indicator or Subscriber ID Unique Enrollee ID

These elements are needed for the health status validation to ensure the particular medical records and claims are for the correct enrollees.

Demographics and Enrollment Data

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HHS-RADV Health Status Data Validation

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The health status of an enrollee is determined by the presence of HCCs which are derived from diagnosis codes [International Classification of Diseases, 9th Revision (ICD-9)/International Classification of Diseases, Tenth Revision (ICD-10)] determined by an enrollee’s RA eligible medical claims and supplemental diagnosis files. In validating the health status of an enrollee, the issuer’s supporting documentation (medical records, original final claims (i.e. 837) and electronic remittance advice (i.e. 835) must support the data in the EDGE server. If the supporting documentation does not support the data in the EDGE server, then the IVA Entity will document identified discrepancies.

Health Status Data Validation

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The enrollee’s medical records must be reviewed to determine the authenticity and validity of the diagnoses on the claims submitted to the EDGE server. Validity of the medical record will be determined by the record’s source, date of service, and presence of a physician’s or applicable non-physician’s credentials and signature. Validity of the enrollee’s diagnoses will be determined through abstraction coding of ICD-9/ICD-10 diagnosis codes from the medical records.

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The process for health status validation is broken into two (2) sections:

Step 1: Medical Record Intake To ensure the medical record matches to the enrollee in the Sample Report and matches to one of the enrollee’s claims identified in the report. Not required to be completed by certified medical coders, and can be completed by a role designated as primary or senior intake reviewers.

Step 2: Medical Record Review and Diagnosis Abstraction Involves review of the medical record to ensure it meets CMS requirements regarding facility type, service code, service type, provider credentials and signature. Diagnosis abstraction. Required to be completed by certified medical coders.


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The purpose of this step in the health status validation process is to ensure medical records are submitted for the appropriate enrollee in the IVA sample and associated to claims submitted to the EDGE server for that enrollee. Involves a three-way match between the demographics on the medical record, the demographics on the claim, and the demographics and enrollment data (which was validated in the demographic and enrollment validation process). Requires a senior intake reviewer to review the medical record to confirm discrepancies found by the primary intake reviewer.


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Primary Intake Reviewer •

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Verifies enrollee’s demographics data on the medical records, claims, within the sample to ensure that all recorded fields match. Flags the enrollee file as an error if there is a discrepancy. Sends enrollee files marked with errors to the senior intake reviewer.

Senior Intake Reviewer Revalidates steps for any sampled enrollees that do not match the demographics data. Compares results from the medical record and claim to the demographic enrollment data. Flags enrollee file as an error if there is a discrepancy. Records validation results.

Health Status Validation – Medical Record Intake

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Below is the process for medical record intake reviewers to perform the medical record intake portion of the health status validation process.


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Intake Reviewers Intake reviewers will review the medical record and claims to validate the medical record and claims are for the correct enrollee. The enrollee’s first and last name, should reasonably match between the documents based upon the IVA Entity’s judgment.

For example, one document may show the name as Michael Smith, whereas the second document may show Mike Smith.


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Intake Reviewers Intake reviewers will review the medical record and claim to determine the enrollee member ID, date of birth and gender from the medical record and claim are an exact match, or for the name, a reasonable match. Identify Statement Covers From date and Statement Covers Through date from both the medical record and the claim to verify that the medical record span falls within the claimed dates of service span. If there is a discrepancy, then the primary reviewer will mark the enrollee file as an error and send the file to the senior reviewer for re-validation.


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Intake Reviewers Compare the results of the medical record and claim review to the validated enrollment and demographics data to ensure that all fields reasonably match. If a variance is found, the intake reviewer will mark the enrollee file as an error and forward to the senior intake reviewer.


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The purpose of this step in the health status validation process is to verify that the medical record meets CMS requirements to validate the issuer submitted data for enrollee risk scores.

The medical record originates from the provider of the medical service(s). The medical record reflects acceptable providers and services.

Must be completed by certified medical coders. Requires a senior coder to review the medical record if discrepancies are found by the primary coder.

Health Status Data Validation - Medical Record Review and Diagnosis Abstraction

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Medical Record Review and Diagnosis Abstraction


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Medical Record Documentation Requirements Medical record must be for the correct enrollee Acceptable medical record source

hospital inpatient outpatient treatment professional medical treatment

Acceptable Bill Type (111, 117, 131, 137, 711, 716, 717, 767, 771, 777) Acceptable Service Code (professional claims) Acceptable service type

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face-to-face visit acceptable telehealth encounter

Medical record date of service must fall within the benefit year Medical record must contain a valid physician or non-physician signature and credentials


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Primary Coder •

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Identifies if institutional or professional from medical record and claim. Compares the facility type and bill type to the RA allowable list. Identifies the type of provider credentials on the medical record and compares to the allowable list. Utilization of CPT/HCPCS codes for professional claims. Identifies ICD-9/ICD-10 diagnoses from the medical record. Records the results. Sends the enrollees with identified errors to the senior coder.


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Senior Coder •

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Performs revalidation of discrepant records. Compares the facility type and bill type to the RA allowable list.

Identifies the type of provider credentials from the medical record and compares to the allowable list. Identifies the ICD-9/ICD-10 diagnosis from the medical record. Utilization of CPT/HCPCS codes for professional claims. Performs IRR on a sample of diagnoses for all primary coders. Records the results.


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Validate that medical records originate from one (1) of the following types of providers of medical services:

Hospital inpatient Outpatient treatment Professional medical treatment


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Determine if the claim and the associated medical record are from an acceptable source by reviewing the claim form type to determine if it is an institutional claim or a professional claim.

Institutional claim (hospital inpatient or outpatient facility) Validate that the bill type code on the original claim is an allowable RA bill type code. If the bill type code on the original claim is not an allowable RA bill type code, the medical record is not acceptable for diagnosis abstraction.

Professional claim (physician or group practice) Validate that the original claim has at least one claim line with an RA eligible Common Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code. If there are no acceptable service codes on the original claim, the medical record is not acceptable for diagnosis abstraction.


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The service code is the CPT or HCPCS code which are used to identify the procedure rendered. The service code qualifier identifies if the service code is CPT or HCPCS. The service code from the claim will be validated against the RA acceptable list to ensure that the service code was acceptable.


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Determine if the medical record documentation was generated as a face-to-face visit or telehealth visit.

The records must be documented and authenticated by a permitted provider.


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• Identify Statement Covers From date and Statement Covers Through date from both the medical record and the claim to verify that the medical record span falls within the claimed dates of service span.


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Provider Credentials A provider is defined as a physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.

Provider Signatures All medical records must have an acceptable provider signature displayed on the document.


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Provider Credentials There are non-physicians with various specialties, including Nurse Practitioners (NP), Physician Assistants (PA) and other health care professional that may be qualified by a state to prescribe and diagnose independently or with additional information supported by a Medical Doctor (MD), Doctor of Osteopathy (DO) or signature attesting to the diagnoses and assessment. The definition of a qualified non-physician practitioner (NPP) varies by state. The medical record reviewer must check the provider’s professional licensure credentials (e.g. MD, DO, NP, PA, etc.) to ensure the provider of record is qualified by the state where the service was provided as noted above. This statement does not mean that the reviewer will check provider credentialing files or procedures.


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The medical coder will review a medical record to abstract diagnosis codes to calculate the enrollee’s risk score. Medical record and diagnosis code abstraction must be performed in accordance with industry standards for coding and reporting. Coders must follow current industry standards as defined in the ICD-9, or the ICD-10 guidelines for coding and reporting.


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Next Steps

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CMS will continue to support stakeholders through the HHS-RADV process by hosting periodic webinar and Q&A sessions.

There will be an opportunity for stakeholders to ask HHS-RADV related questions during the webinar sessions as well as during the Q&A sessions.

Next Steps: Training Sessions

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Date Time Dec 23, 2015 11:30 a.m. – 12:30 p.m. ET

Next Steps: Training Sessions (continued)

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Upcoming Q&A Sessions



Stakeholders can access additional documents at https://www.REGTAP.info in the REGTAP Library.

Locating HHS-RADV Documents in REGTAP

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Under Program Area, select “HHS-Operated Risk Adjustment Data Validation”




Questions?

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To submit or withdraw questions by phone: •

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dial ‘14’ on your phone’s keypad to submit your question.

dial ‘13’ to withdraw your question.

To submit questions by webinar: type your question in the text box under the ‘Q&A’ tab.



Resources

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Resource Resource Link U.S. Department of Health & Human Services http://www.hhs.gov/

Centers for Medicare & Medicaid Services (CMS) http://www.cms.gov/The Center for Consumer Information & Insurance Oversight (CCIIO) web page

http://www.cms.gov/cciio

Consumer website on Health Reform http://www.healthcare.gov/Registration for Technical Assistance Portal (REGTAP) - presentations, FAQs

https://www.REGTAP.info

Patient Protection and Affordable Care Act (ACA) http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html

HHS Notice of Benefit and Payment Parameters for 2014 and Amendments to the HHS Notice of Benefit and Payment Parameters for 2014 (‘Payment Notice 2014’)

http://www.gpo.gov/fdsys/pkg/FR-2013-03-11/pdf/2013-04902.pdf

Resources

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http://www.hhs.gov/

http://www.cms.gov/

http://www.cms.gov/cciio

http://www.healthcare.gov/


http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html

http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html




Resource Resource Link HHS Notice of Benefit and Payment Parameters for 2015 and Amendments to the HHS Notice of Benefit and Payment Parameters for 2015 (‘Payment Notice 2015’)


Standards Related to Reinsurance, Risk Corridors and Risk Adjustment under the ACA (‘Premium Stabilization Rule’)


Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014


Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2016. Final Rule, 45 C.F.R.§144, 146, 147, et al. (‘Payment Notice 2016’)

https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-03751.pdf

Resources (continued)

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Resource Resource Link Affordable Care Act (ACA) HHS-Operated Risk Adjustment Data Validation (RADV) Process White Paper, June 22, 2013

https://www.regtap.info/uploads/library/ACA_HHS_OperatedRADVWhitePaper_062213_5CR_062213.pdf

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Resources (continued)






Select “Submit an Inquiry” from My Dashboard.

Inquiry Tracking and Management System (ITMS)

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Stakeholders can submit inquiries to ITMS at https://www.REGTAP.info


http://www.regtap.info/


FAQ Database on REGTAP

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FAQ Database is available at https://www.regtap.info/

The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary categories, and Publish Date.




Closing Remarks

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