What is the primary goal of RADV audits for health plans?

The primary goal of Risk Adjustment Data Validation (RADV) audits for health plans is to ensure compliance and accurate risk adjustment. This process involves verifying that the data submitted by health plans to support risk adjustment and reimbursement is accurate and reflects the true health status of the member population.

Accurate risk adjustment is essential for adequate funding and resources allocation to health plans, allowing for a proper reflection of the risk levels of enrollees. By conducting RADV audits, government agencies can validate the diagnoses and other relevant data that impact risk scores, thereby ensuring that health plans are reimbursed correctly based on the health status of their members.

This focus on compliance not only helps in maintaining the integrity of the healthcare system but also promotes fair competition among health plans, as it holds them accountable for the accuracy of the information they report. Maintaining such standards protects the overall model of risk adjustment used in Medicaid and Medicare programs, which is vital for the sustainability of healthcare funding and resources.