Multi-Agent Audit Orchestration
ACA AuditShield™ deploys AI to simulate HHS-RADV audit scenarios before they occur. Independent agents replicate CMS sampling methodology, validate end-to-end evidence traceability from source charts through EDGE server submissions, and assess documentation sufficiency using LLMs fine-tuned on RADV error patterns and audit outcomes. By identifying exposure early, issuers can remediate discrepancies proactively and protect transfer payment revenue.
Why HHS-RADV Matters for ACA Issuers
CMS conducts Risk Adjustment Data Validation (RADV) audits under the ACA risk adjustment program to verify that diagnoses submitted through the EDGE server are supported by clinical documentation. Audits can result in significant financial consequences: transfer payment adjustments, recoupments, and compliance penalties.
Unlike Medicare Advantage RADV (which has been well-established for years), HHS-RADV for the ACA marketplace is an evolving program with increasing scrutiny. Issuers must demonstrate that every diagnosis contributing to their risk scores — whether from claims or supplemental diagnosis files — is supported by acceptable documentation and complies with CMS coding guidelines.
The stakes are real: a single audit finding can trigger transfer payment recalculations affecting millions in revenue. Issuers that cannot produce organized, defensible evidence face longer audit cycles, higher recoupment risk, and reputational damage.
The Challenges We Solve
Documentation Gaps
Charts may be incomplete, lack specificity, or miss required evidence elements. Diagnoses submitted to the EDGE server without sufficient clinical documentation are vulnerable to audit overturns.
Traceability Breakdown
Connecting a diagnosis in an EDGE server submission back through the supplemental diagnosis file, the chart review decision, and the source clinical document is a manual, error-prone process.
Audit Response Bottlenecks
When CMS requests audit documentation, issuers scramble to locate charts, compile evidence, and assemble binders. Manual preparation takes weeks and increases the risk of missed deadlines.
Unknown Exposure
Without proactive monitoring, issuers cannot quantify their RADV risk. Unsupported diagnoses, documentation quality issues, and coding inconsistencies remain hidden until an audit reveals them.
Supplemental Dx Vulnerability
Supplemental diagnoses derived from chart reviews face heightened audit scrutiny. Issuers must prove acceptable source documentation, proper coding, and legitimate clinical basis for every supplemental code.
Cross-Year Complexity
RADV audits may cover multiple benefit years. Maintaining consistent evidence quality across years, tracking enrollment changes, and managing document retention adds operational complexity.
How ACA AuditShield™ Works
Continuous Risk Assessment
AI agents continuously scan your EDGE server submission portfolio to identify diagnoses with weak or missing documentation support. Every HHS-HCC contributing to your risk scores is scored for audit vulnerability based on documentation completeness, coding specificity, and source traceability.
Evidence Validation
For each diagnosis flagged as vulnerable, ACA AuditShield™ retrieves the supporting documentation from ACA ChartCopilot™ (for supplemental diagnoses) or from claims-linked source records. AI validates that documentation meets CMS evidence standards, including clinical relevance, date alignment, provider attribution, and coding specificity.
RADV Scenario Simulation
Simulate audit outcomes using CMS sampling methodology. Model which members and diagnoses are most likely to be selected, estimate the financial impact of potential findings, and identify the specific documentation gaps driving the greatest recoupment exposure.
Proactive Remediation
Route documentation gaps to coding teams, providers, and compliance staff with clear action items: obtain missing records, request provider addenda, correct coding errors, or prepare justification narratives. Task queues with priority rankings ensure high-impact items are addressed first.
Automated Binder Assembly
When an audit is initiated, ACA AuditShield™ generates member-level evidence binders containing: source clinical documents, coding rationale, HHS-HCC mapping, EDGE server submission records, and chronological evidence summaries. Binders are formatted for CMS reviewer expectations and ready for submission within days, not weeks.
Track & Report
Monitor audit progress, response deadlines, CMS communications, and remediation status through a centralized command center. Post-audit analytics identify systemic issues for process improvement and future risk reduction.
Key Capabilities
RADV Command Center
Centralized dashboard for audit planning, exposure tracking, deadline management, and response coordination. Real-time visibility into audit-ready status across all plans and benefit years.
Evidence Explorer
Side-by-side viewer showing source clinical documentation alongside EDGE server submissions, HHS-HCC mappings, and risk score contributions. Highlighted evidence passages with page/section references.
Dynamic Binder Builder
Auto-generate audit workpapers customized for CMS RADV submissions, internal compliance reviews, or external consultant engagements. Configurable templates with section ordering and evidence packaging rules.
Sampling Simulator
Model CMS audit sampling scenarios using published methodology. Estimate which members and diagnoses are likely to be selected and project financial exposure under different finding rates.
Submission Integrity Checker
Validate that every EDGE server submission — enrollment, claims, and supplemental diagnoses — has complete and traceable documentation support. Flag submissions where evidence gaps create audit risk.
Remediation Workflows
Task queues for coders, auditors, providers, and compliance staff with priority rankings, assignment rules, due dates, and escalation paths. Dual-control approval ensures no remediation action goes unchecked.
Cross-Year Archive
Maintain indexed, searchable evidence archives across multiple benefit years. Document retention policies, version tracking, and chain-of-custody logging for long-term audit defense.
Provider Quality Analytics
Track documentation quality by provider, practice, and specialty. Identify recurring documentation errors, coding inconsistencies, and training needs. Generate targeted education reports for provider engagement.
End-to-End Traceability
ACA AuditShield™ maintains a complete evidence chain for every diagnosis contributing to your ACA risk scores:
Every link in this chain is documented, timestamped, and retrievable for audit defense.