Navigating CMS’s Aggressive RADV Audit Strategy: How MA Plans Can Strengthen Compliance and Performance
By RaeAnn Grossman
The Centers for Medicare & Medicaid Services (CMS) has officially turned up the heat on Medicare Advantage (MA) plans. With the announcement of an “aggressive” overhaul of its Risk Adjustment Data Validation (RADV) audits, CMS is set to annually review every MA contract while fast-tracking the backlog of audits from payment years 2018 through 2024.
This sweeping shift follows CMS’s goal of recouping $4.7 billion in MA plan overpayments—an unprecedented move that elevates the urgency for health plans to reassess their coding practices, data integrity, and compliance infrastructure.
At HLTHWorks, we examine the impact of this escalation and outline data- and tech-driven strategies that can empower plans to thrive in a new era of accountability.
Understanding the Shift: From Selective to Comprehensive Oversight
Historically, CMS audited roughly 60 MA contracts per year. That narrow scope has expanded dramatically in response to concerns over unsupported diagnosis codes leading to systemic overpayments. CMS’s final rule also eliminated the fee-for-service (FFS) adjuster, intensifying financial consequences and making data completeness and coding accuracy mission-critical.
In this environment, plans face rising audit volumes, compressed timelines, and potentially billions in financial penalties. The only path forward is one of preparedness, innovation, and execution.
Strategy #1: Enhance Coding Accuracy with Advanced Technology
MA plans must elevate their coding accuracy and documentation integrity. Technologies like AI, machine learning, and natural language processing (NLP) can detect documentation gaps, flag questionable diagnoses, and spotlight inconsistencies in real time.
These tools help coding teams:
- Focus on high-risk areas within complex medical records
- Identify HCC mismatches by provider type or site of service
- Pinpoint conditions misaligned with clinical context or specialty scope
However, AI alone is not a silver bullet. Continuous human oversight, AI performance monitoring, and coder training are essential to ensure technology adds value and maintains compliance. Plans should invest in:
- A centralized compliance framework
- Defined coding protocols
- Regular chart audits
- Dynamic quality assurance programs
Strategy #2: Strengthen Provider Collaboration for Audit Readiness
Provider engagement is essential for RADV success. MA plans must proactively partner with clinicians to ensure documentation is:
- Timely
- Specific
- Aligned with HCC reporting requirements
Key tactics include:
- Provider education on audit processes and documentation expectations
- Enabling interoperability via national exchanges and direct EMR integration
- Conducting Health Risk Assessments (HRAs) and ensuring follow-up with primary care physicians
Given that the Office of Inspector General (OIG) continues to scrutinize payer practices around HRA data, it’s critical to verify that diagnoses identified in assessments are validated and reflected in ongoing patient care.
Strategy #3: Leverage Government and Industry Resources
Plans should equip their teams with the latest tools and knowledge:
- Ensure audit teams are trained on current RADV protocols and CMS updates through the REGTAP platform
- Utilize the OIG’s high-risk diagnosis toolkit, which includes SQL scripts to help replicate CMS’s audit logic and target likely problem areas
- Conduct internal chart reviews using CMS’s logic to validate diagnosis integrity ahead of external audits
Having this knowledge embedded across the compliance and coding organization arms MA plans with the confidence and precision needed in high-stakes audits.
Strategy #4: Deploy Prospective and Retrospective Analytics for Risk Mitigation
To meet CMS’s demand for accuracy, health plans must deploy both:
- Prospective analytics at the point of care to confirm documentation aligns with the patient’s risk profile
- Retrospective analytics to review past submissions, close coding gaps, and proactively correct inaccuracies
Prioritizing charts with the highest financial and compliance risk can help optimize audit preparation efforts. Plans should also consider implementing a second-pass review process—a growing best practice in an era of heightened audit complexity.
Success in a High-Stakes Compliance Environment
CMS’s aggressive RADV strategy marks a new era for Medicare Advantage plans—one that requires equal parts technological sophistication, operational agility, and human expertise.
By integrating these four strategies—advanced coding tools, provider alignment, government resources, and predictive analytics—MA plans can stay ahead of audits while improving the integrity of their risk adjustment programs.
At HLTHWorks, we believe this isn’t just about compliance. It’s about building smarter, more resilient systems that ultimately support better member care and sustainable growth. Now is the time for MA leaders to transform RADV preparation into a strategic advantage.
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