Risk Mitigation

Guarding against the financial consequences of a RADV Audit by revealing Risk Factors that cannot be validated and Providers who are not documenting and coding properly

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.

Key features of the industry’s best defense against costly RADV Audit penalties:

  • Identifies and quantifies the conditions and providers who are putting the plan at risk
  • Provides “actionable” results, primed for research, correction,and provider education
  • Removes your “False Positives” without increasing your “False Negatives”
  • Supports both HHS RADV and Medicare RADV Audits

Valid8 was designed to expose such risks, so that the associated claims and submission data can be adjusted properly. As the HCCs and risk adjustment models differ in each government program, Pulse8 offers versions of Valid8 specific to ACA Commercial and Medicare Advantage.Valid8 analyzes conditions with the greatest risk of failing a data validation audit. Just as Calcul8 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 on an HCC-specific basis, as well as a program extrapolation basis.

Just as Calcul8 supports your revenue goals in the identification of persisting and suspecting conditions, Valid8 highlights those HCCs at potential risk for RADV Audit. Taken together, Calcul8 and Valid8 ensure that you safely get your risk-adjusted fair share – while also 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 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.

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