Blog banner

The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Choosing an Initial Validation Audit Vendor: Health Plans Should Start Now


By Anita Nair Hartman/Monday, December 15, 2014


EDGE server data submissions, cost-sharing reduction reconciliations, risk optimization, and now the initial validation audit (IVA) – Affordable Care Act (ACA) compliance has created multiple challenges for health plans, with complicated and ever-changing regulations draining their resources. For the IVA, Centers for Medicare & Medicaid Services (CMS) requires health plans to hire an independent auditor with certified coders to review and validate EDGE server data. CMS developed the IVA requirements to ensure that the membership and risk adjustment information health plans submit to the EDGE servers for eventual payment transfer calculations is accurate and complete. The current deadline to select a vendor is March 31, 2015.

To manage the complex challenges of the ACA regulations, health plans have used a mix of internal resources and third-party vendors. The IVA is one requirement that health plans can’t, by virtue of the law, handle by themselves. Medical records are a critical part of the validation process, so health plans need to be careful to select a vendor with the right experience and certification. Some important qualities that health plans should look for in an IVA vendor are:

 

  • Deep knowledge of ACA regulations. A qualified vendor should have a history of monitoring, evaluating, and influencing the changing ACA requirements.
  • Data, analytics, and auditing experience. A long history analyzing large claims databases and auditing healthcare claims, and prior experience with CMS-mandated reporting are critical experiences.
  • Experience with EDGE servers. To efficiently audit EDGE data, the vendor needs experience with EDGE data format and content, and in processing large amounts of claims data. 
  • Risk and reinsurance expertise. Look for an auditor with experience building reinsurance and risk models.
  • Customizable approach. This is not a completely straightforward process. Every health plan is different, and the right vendor will be able to implement a solution to meet a health plan’s specific needs.
  • Certified coders. This one is straightforward. By law, the coders must be certified by the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

Although CMS is currently considering delaying the IVA auditor selection deadline beyond March 31, 2015, health plans should not delay in making a decision. Selecting a partner to support the IVA will give health plans peace of mind in managing the IVA requirements – which CMS continues to finalize. Selecting a qualified vendor should be a thoughtful and informed process, and the time to prepare is now.

Anita Nair-Hartman, Vice President, Market Planning and Strategy
Bryan Briegel, Director, Operations

Americans Not Concerned with Data Privacy — For the Most Part


By Truven Staff/Monday, December 1, 2014
Truven Health recently conducted a nationwide poll, in conjunction with NPR, to investigate data privacy concerns. The results? Generally, Americans are comfortable with the idea that medical data is shared with employers and health plans. Most of us are willing to share our anonymized data with health researchers. Most of our providers have electronic medical records, and many of us have reviewed our own information. We don’t have a lot of reason to worry about unauthorized access; barely 5 percent have ever been notified of a security breach. 

But we don’t want to share everything with everyone. Our Chief Medical Officer, Dr. Michael Taylor, was shocked to learn that more than three-quarters of Americans would not be willing to share their social and credit card data with their providers and health plans, even if it would improve their overall health. 

NPR’s take on the poll: medical data privacy is not a big concern for most people. Our take: As always, we prefer to let the data speak for itself.

RSS