The financial risks of a Data Validation Audit can be substantial as CMS and HHS assume the rate of unsupported HCCs in its sample is representative of the error rate in your overall population and apply penalties proportionately. Just one unsupported condition, if selected for the RADV audit sample, can have a huge impact.
Valid8 was designed to expose such risks, so that the associated claims can be withheld from submission or deleted after submission. As the HCCs and risk adjustment models differ in each government program, Pulse8 offers versions of Valid8 specific to ACA Commercial, Medicare Advantage, and Managed Medicaid.
Valid8 analyzes conditions with the greatest risk of failing a data validation audit, whether or not they have been submitted to the EDGE server, CMS (EDPS/RAPS), or Medicaid (MEDS II), and assesses the strength of the data supporting each condition. Just as Reveal8 estimates the confidence that a condition exists or likelihood that an opportunity will close on its own, Valid8 estimates the probability that it has found a bona fide coding risk and then quantifies the financial exposure of each. Taken together, Reveal8 and Valid8 ensure that you safely get your risk-adjusted fair share – while managing your audit risk.
Pulse8 has leveraged data mining and our collective experience with data validation exercises to identify conditions that are less apt to be coded correctly and more susceptible to being audited. Valid8 also identifies those providers and groups whose poor documentation habits are putting the plan at greater risk. Valid8’s results can be viewed by provider and geography on the basis of:
Valid8 is the “voice of caution” in Pulse8’s product suite, charged with reducing the likelihood that risk-bearing entities get penalized from a Data Validation Audit.