RA and RADV Predictive Modeling and Methodology Evaluation
Description
(Marketplace) Risk adjustment data validation (RADV) is the audit of HHS-operated Risk Adjustment (RA). KPMG, the main RADV contractor, seeks to conduct predictive modeling and simulations of proposed policy changes. KPMG also validates the RA models (ML-based) and evaluates the RADV methodology.
Detailed example
Better decision-making ability for proposed policy changes. Ensure integrity and validity of RA models, which are complex ML-based models.
AI / analytics pattern
Classical/Predictive Machine Learning: Models trained on data to make predictions or classifications based on identified patterns or relationships.
Automation level / stage
a) Pre-deployment – The use case is in a development or acquisition status.
Expected benefit
Predictive modeling and simulations of policy changes are used to determine likelihood of various outcomes across markets, by individual issuer, etc. Model validation and methodology evaluation determine effectiveness, fairness, and impacts of the programs.
Controls / human review
ATO: Not reported; PIA: Not published