CMS Audits: 4 Strategies for RADV Compliance
- The Centers for Medicare & Medicaid Services (CMS) is intensifying its oversight of Medicare Advantage (MA) plans thru risk Adjustment Data Validation (RADV) audits.
- this aggressive approach follows CMS's goal to recover $4.7 billion in overpayments. MA plans must now reassess their coding and compliance strategies to avoid penalties.
- Previously, RADV audits scrutinized about 60 contracts per payment year.
the centers for Medicare & Medicaid Services (CMS) are increasing Risk Adjustment Data Validation (RADV) audits, making compliance crucial for Medicare Advantage plans. Discover four key strategies to fortify your audit readiness adn coding accuracy. This shift is driven by CMS’s intensified oversight and the aim to recover billions in overpayments, impacting how plans reassess their coding and compliance. Enhance coding accuracy with AI and analytics, foster vital provider collaboration, leverage industry resources, and deploy targeted capabilities. These steps can help you navigate these heightened audit surroundings. News Directory 3 provides expert insight and resources to guide plans through every stage of the process. Do you want to know how to make the most of RADV audits? Find out!
Medicare Advantage Plans Face Increased Scrutiny From CMS RADV Audits
Updated June 10, 2025
The Centers for Medicare & Medicaid Services (CMS) is intensifying its oversight of Medicare Advantage (MA)
plans thru risk Adjustment Data Validation (RADV) audits. CMS aims to review every MA contract annually and
expedite audits from 2018-2024.
this aggressive approach follows CMS’s goal to recover $4.7 billion in overpayments. MA plans must now
reassess their coding and compliance strategies to avoid penalties.
Previously, RADV audits scrutinized about 60 contracts per payment year. The expanded scope addresses concerns
over unsupported diagnosis codes leading to overpayments. The elimination of the fee-for-service adjuster
increases the pressure on plans to ensure coding accuracy and compliance.
Experts recommend four strategies for MA plans to bolster audit readiness:
- Enhance Coding Accuracy: Use AI and analytics to monitor coding quality and identify high-risk
diagnosis codes. These tools can highlight gaps and inaccuracies in medical records. - Foster Provider Collaboration: Engage provider networks to ensure accurate documentation. Align
practices with hierarchical condition category (HCC) reporting requirements. - Leverage Industry Resources: Use CMS materials and tools from the Registration for Technical
Assistance Portal (REGTAP). Integrate resources like the OIG toolkit to identify high-risk diagnosis codes. - Deploy Targeted Capabilities: Use prospective and retrospective analytics to ensure complete and
accurate documentation. Prioritize charts with the highest risk of coding gaps.
A second review of coding results can further improve accuracy, becoming an industry standard amid increased
audit scrutiny.
By adopting these strategies, health plans can navigate the heightened audit surroundings, enhance member care,
and improve operational efficiency. CMS’s new RADV audit strategy emphasizes the importance of coding accuracy,
provider collaboration, and strategic use of analytics for Medicare Advantage plans.
What’s next
Medicare Advantage plans must view RADV audits as an opportunity to refine processes,strengthen compliance,and
invest in technology and expertise. Preparing for annual audits requires foresight and a commitment to
continuous improvement.