Preparing for CMS RADV Audits

As CMS intensifies its Medicare Advantage Risk Adjustment Data Validation (RADV) audits—vowing to review every MA contract annually and accelerate payment-year reviews from 2018 onward—health plans must evolve from reactive defense to proactive readiness.

At HLTHWorks, we believe audit success begins with precision, not panic. Now is the time to strengthen your retrospective coding programs, reinforce your internal processes, and build a future-proof compliance roadmap. Below are key strategies we recommend for preparing for RADV audits with confidence and control.

1. Increase Your First-Pass Coding Quality Assurance

Your first line of defense starts with first-pass QA. Most health plans and vendors only sample a small percentage of initial coding work. That’s no longer enough. Upping your first-pass QA percentage—especially on charts flagged with high-value conditions or common errors—can prevent audit triggers, reduce downstream work, and improve risk score reliability. Use targeted audits with proven QA algorithms to surface documentation gaps and coding inconsistencies early.

2. Run 100% Second-Pass Reviews on Claims-Linked Records

A compliant risk adjustment program should not end after the first review. By implementing a 100% second-pass coding review on claim-linked records, you ensure completeness and accuracy across the coding lifecycle. This layer of validation aligns the medical record with claim data and enhances defensibility under RADV scrutiny. HLTHWorks’ second-pass teams use a combination of human coders, AI-supported NLP, and proprietary audit protocols to maximize both accuracy and yield—without increasing risk.

3. Revisit and Strengthen Your Internal Coding Policies

RADV audits often expose outdated or ambiguous internal coding policies. Now is the time to assess your internal guidelines against current CMS guidance, ICD-10 updates, and OIG recommendations. HLTHWorks can perform a policy gap analysis and refresh documentation protocols to ensure your policies support defensible coding—especially in areas such as chronic condition capture, MEAT criteria, and encounter documentation standards.

4. Leverage OIG Toolkits and CMS Audit Models

Don’t wait to see how an auditor interprets your documentation. Get ahead by aligning your review protocols with OIG toolkits and CMS’s current RADV audit model. These tools can guide your internal validation efforts, prioritize common risk areas (e.g., diabetes, vascular disease, cancer), and help simulate audit scenarios before CMS ever knocks on your door.

5. Implement Virtual Coding Scribes in High-Volume Practices

Your coding is only as good as the documentation it’s based on. Virtual coding scribes can be a game-changer for high-volume clinics and provider groups. By embedding compliant, real-time coders into your workflow, you capture more complete ICD-10 diagnosis codes and ensure alignment between clinical documentation and billing. HLTHWorks offers trained scribes who specialize in chronic condition capture, HCC alignment, and compliant EHR documentation.

6. Partner with HLTHWorks to Build a RADV Readiness Roadmap

Navigating RADV audits isn’t a one-size-fits-all journey. HLTHWorks partners with health plans to create customized RADV readiness roadmaps that align with your data, technology, and provider ecosystem. We combine regulatory expertise, audit simulation, coder training, and analytics to reduce error rates and elevate audit preparedness across Medicare Advantage, D-SNP, and other risk-bearing products.

Get RADV Ready—Now

Audit season is no longer a future concern—it’s a current imperative. Whether you need to redesign your QA program, improve retrospective coding workflows, or integrate audit-aligned processes across your organization, HLTHWorks is here to help.

Let’s build your RADV readiness strategy today. Contact us to schedule a discovery session and learn how HLTHWorks can support your journey toward compliant, accurate, and high-performing risk adjustment.