HealthLeaders Media: CMS Final Rule Amends Risk Adjustment Data Validation Program

“The Centers for Medicare & Medicaid Services this week issued a final rule to amend the methodology for the Department of Health and Human Services’ risk adjustment data validation (HHS-RADV) program.”

“After collecting stakeholder feedback, CMS says the final rule ‘will give states and insurers more stability and predictability, promote program integrity, and foster increased competition.’”

“‘These changes will also promote fairness by ensuring that insurers are not penalized in HHS-RADV when a difference in diagnosis for an enrollee has no effect on risk, as well as by ensuring that insurers that receive adjustments are receiving adjustments in proportion to the errors identified through HHS-RADV,’ CMS said.”

“The first change refines the HHS-RADV error rate calculation, which is based on the insurers’ ‘failure rate,’ a metric that validates diagnoses and conditions associated with enrollees selected for audit.”

“The final rule will also:

  • Modify grouping medical conditions in HHS-RADV within the same hierarchical condition category (HCC) coefficient estimation groups in risk adjustment to determine failure rates for those HCCs…” Read the full article here.

Source: CMS Final Rule Amends Risk Adjustment Data Validation Program – By John Commins, November 25, 2020. HealthLeaders Media.

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