The Affordable Care Act has led to the creation of the Health Insurance Exchange (HIX) Marketplace. As a result, HHS/CMS will require that a sample of risk adjustment data from all Qualified Health Plans (QHP) be validated (Risk Adjustment Data Validation) by external auditors. With our expertise, we can help you ensure that your risk scores are supported by accurate data, and that there will be no negative impact on your bottom line.

How to meet this new requirement

The goal of this new requirement by HHS/CMS for newly created QHPs is to mitigate the impacts of potential adverse selection.

The Validation process will help to identify the error rate, and then allow HHS/CMS to adjust the average actuarial risk for each QHP. It is this process that could result in adjusted payments/charges.

Obviously this type of risk adjustment model will generate winners and losers because of the required transfers between plans. This means it’s critical to start preparing now so you can give your QHP the time needed to make sure that data being generated will not adversely affect your QHP’s bottom line!

It is clear that a only proactive approach on the part of the plans and the audit firm will ensure that your QHP reports accurate risk scores. By eliminating inaccurate data, you can protect payment transfers between issuers within a State’s exchange. So the sooner you take the first step, the better.

For more information and/or contracting please contact: Paul Ackroyd at 717-802-1821 or