Insurers Now Required by CMS to Conduct Audit for ACA's Risk Adjustment Program

Posted:April 6, 2016

(Updated: Oct. 6, 2016)*

* Note: Letters were mailed to select Providers in late August 2016.

Starting in 2016, the CMS requires all insurers selling ACA-compliant, on- and off-exchange, individual and small group plans to perform an annual Initial Validation Audit (IVA) to ensure high quality data is used when assessing the payment transfers for the ACA’s Risk Adjustment (RA) program. Therefore, Blue Cross and Blue Shield of Texas (BCBSTX) is asking for your cooperation and participation in the required Initial Validation Audit (IVA).   

Since insurers are required to retain an independent auditor to perform the requirements of the IVA, BCBSTX will be working with Tactical Management Incorporated (TMI) to retrieve medical records. The RA program applies to all ACA compliant individual and small group plans, both on-and-off the exchange and conducts a calculation based on enrollee risk. As you are aware; enrollee risk is calculated based on the diagnosis codes submitted on a claim, as well as through supplemental code capture through medical record review. As BCBSTX providers, you may be asked to provide medical records directly to our retained auditor, TMI, in order to validate all of the diagnosis codes used in the RA calculation within the time frame requested. The IVA requires medical records in order to validate the claims data to CMS on an annual basis. It is of utmost importance that you respond to these requests timely.

The IVA will be performed on a sample of enrollees enrolled in ACA compliant plans. Again, this includes individual and small group plans, both on-and off-the exchange. The IVA auditor will validate medical claims of the sampled enrollees from the previous year. For example, this audit will be conducted in 2016, but will review mainly claims with dates of service in 2015. Please be aware some of these claims may have been paid in 2016 and are likely to be included in the sample.

We understand that this is a very busy time; however, in an effort to complete the audit, we appreciate your full support and cooperation as you receive requests from TMI and delivery of the medical record(s) in a timely manner. The IVA will help confirm that the valuable care you provide to your patients every day is accurately reflected in the data that you provide to auditors for CMS records.  

Additional information will be provided in the upcoming months. Please feel free to contact a Network Management Representative if you have any questions or if you need additional information. For our convenience, a list of the BCBSTX Network Management offices and their telephone/fax numbers is included below.