Advanced AI/ML Solution Improves Risk Score Accuracy and RADV Audit Readiness for Health Plans
Inovalon, a leading provider of solutions empowering data-driven healthcare, today announced an expansion of its collaboration with Amazon Web Services (NASDAQ:AMZN), further enhancing its Converged Record Review™ solution. The solution accommodates the latest regulatory requirements after the Centers for Medicare & Medicaid Services (CMS) announcement requiring annual Risk Adjustment Data Validation (RADV) audits for all Medicare Advantage (MA) contracts, beginning in 2026.
Health plans operate under increased scrutiny of their clinical support for submitted diagnoses, and face operational burden, potential reputational harm, and additional risk exposure in the event of payment recoupment due to insufficiently supported claims. Converged Record Review, powered in part by Amazon Comprehend Medical's natural language processing (NLP) and machine learning (ML) capabilities, helps MA plans proactively prepare for RADV audits by:
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Enabling rapid evaluation of potential documentation gaps to reduce audit risk
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Integrating with Inovalon's Converged Risk Surveillance Analytics™ to proactively identify and remove unsupported diagnoses
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Streamlining chart reviews and validating diagnoses during RADV audits by surfacing the most clinically relevant information from medical records
Converged Record Review and Converged Risk Surveillance Analytics help MA plans through two critical aspects of RADV preparedness: Hierarchical Condition Category surveillance and retrospective audit support, helping validate submitted diagnoses. These combined capabilities streamline audit processes, while helping to improve risk score accuracy and accurate reimbursements. Inovalon's Converged Risk solution portfolio, which includes these capabilities, was also recognized in the Gartner Market Guide for U.S. Healthcare Risk Adjustment Solutions.
"CMS is raising the bar on RADV audit expectations and Medicare Advantage plans must act quickly to prepare for 2026," said Michael Jones, President of Inovalon's Payer Business Unit. "Expanding our collaboration with AWS allows us to provide our health plan customers with the intelligence, infrastructure, and confidence they need to safeguard revenue and maintain compliance while preparing for RADV audits in a high-stakes environment."
"Industry partnerships like the one with Inovalon help the healthcare and life sciences ecosystem meet challenges to the delivery of care, supporting patients, members, customers, and critical regulatory compliance. There is no compression algorithm for experience, and we are deeply committed to helping Inovalon turn industry expertise, innovation, and the latest technology into a material benefit for their customers," explained - Matt Carr, Director, AWS HCLS US.
For more information about Converged Record Review and how it can help your organization prepare for CMS RADV audits, improve risk score accuracy, and ensure accurate reimbursements, please visit www.inovalon.com/radv-audit/.
About Inovalon
Inovalon is a leading provider of cloud-based SaaS solutions powering data-driven healthcare. The Inovalon ONE® Platform brings together national-scale connectivity, real-time primary source data access, and advanced analytics into a sophisticated cloud-based platform empowering improved outcomes and economics across the healthcare ecosystem. The company's analytics and capabilities are used by over 50,000 active, licensed customers, and are informed by the primary source data of more than 92 billion medical events across 1.1 million physicians, 703,000 clinical settings, and 414 million unique lives. For more information, visit www.inovalon.com.
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Tom Paolella
Sr. Director, Press and Analyst Relations, Inovalon
Thomas.Paolella@inovalon.com
