Earlier this year, the Centers for Medicare & Medicaid Services (CMS) announced significant changes to Risk Adjustment Data Validation (RADV) audits, moving from a model of selective oversight to an annual requirement for every eligible Medicare Advantage plan. With larger sample sizes, shorter submission windows, and extrapolated penalties, what used to be an occasional compliance exercise has become a business-critical priority. And the risks, be they financial, operational, or reputational, are real… and growing.
Our new insight brief, RADV mastery: HCCs, documentation, and the path to RADV audit success, examines what the CMS changes are and what they mean, the pivotal role of precise clinical documentation, and includes a helpful checklist to keep key stakeholders on track. Download the brief here or check out the excerpt below for more on the implications for payers, providers, and payviders.
Shared stakes, shared responsibility
For payers, the implications of this RADV evolution are far-reaching. The expansion introduces increased financial exposure, not only through expensive extrapolated recoveries but also through downstream effects such as degraded Star Ratings and heightened regulator attention. At the same time, the operational burden intensifies as chart retrieval, coding validation, audit response, and legal review demand sustained, high-volume readiness across teams. To keep pace, plans must embed audit response capabilities into everyday risk adjustment operations – no longer as an exception, but as a norm.
Providers, meanwhile, are being drawn deeper down the audit trail. Since every HCC starts with an ICD-10-CM diagnosis documented at the point of care, clinical teams are now accountable not just for accuracy, but for specificity. Diagnoses must be documented in a way that clearly reflects the patient’s condition, a task often guided by the industry standard M.E.A.T. criteria (Monitor, Evaluate, Assess/Address, Treat). And the implications of errors or omissions are both financial and reputational: if provider documentation falls short of what’s required, the result is gaps in care, revenue loss, and audit friction, all of which can strain relationships with payer partners.
The impact is amplified for payviders, those who deliver and administer care under value-based arrangements. They carry the risk-adjusted payment responsibility while also managing the clinical documentation required to defend it. The need to harmonize coding, compliance, and care delivery workflows is urgent, and for those who straddle the payer-provider divide, the stakes couldn’t be higher.
