RADV Audits: What Healthcare Compliance Professionals Need to Know

Jessica Zeff
Aug 19
3 min read

Navigating healthcare compliance can be overwhelming, especially as oversight and regulation continue to intensify. One area drawing increased attention from both federal and state agencies is Risk Adjustment Data Validation (RADV) audits. These audits play a critical role in verifying that healthcare organizations are accurately reporting patient diagnoses and services, particularly under Medicare Advantage (MA) plans.

In this blog, we’ll break down the essentials of RADV audits, explain recent changes in audit scope, and offer practical strategies healthcare compliance professionals can use to prepare, respond, and reduce organizational risk.

What Is a RADV Audit?

RADV audits are conducted by the Centers for Medicare & Medicaid Services (CMS) to confirm the accuracy of diagnosis codes submitted by MA plans for risk adjustment. These codes directly impact how much a health plan is reimbursed for patient care—making accurate coding not just a compliance issue but also a financial one.

When a healthcare provider submits diagnosis codes that don’t match the documentation found in the patient’s medical records, it triggers a compliance issue. If discrepancies are uncovered during an audit, CMS may recover overpayments, putting significant financial pressure on the organization.

The purpose of RADV audits includes:

Verifying that billing codes accurately reflect clinical documentation
Ensuring compliance with federal reimbursement standards
Preventing overpayments and fraud in Medicare Advantage programs

Why RADV Audits Are More Important Than Ever

While RADV audits have existed for years, their scope and intensity have recently expanded. In a major policy shift, CMS now plans to audit every Medicare Advantage plan annually, a substantial increase from the approximately 60 plans reviewed in the past.

This expansion significantly raises the stakes for healthcare organizations. Not only is the number of audits increasing, but the volume of patient records being reviewed is also on the rise.

This creates several challenges for compliance teams:

Increased administrative workload managing multiple, overlapping audits
Higher risk of financial penalties due to coding discrepancies
Greater operational complexity in coordinating internal and external audit responses

💡 Pro tip: Proactively auditing your own coding and documentation before CMS steps in can make a substantial difference.

Understanding the RADV Audit Process

The RADV audit process follows a structured set of phases. Knowing what to expect can help your team prepare effectively and reduce the risk of last-minute surprises.

Typical stages of a RADV audit include:

Sample Selection – CMS selects a random or targeted sample of patient records.
Medical Record Request – Organizations are asked to provide supporting documentation.
Internal Review – Records are internally reviewed for completeness and accuracy.
Submission – Documents are submitted to CMS auditors.
Follow-Up – CMS may request clarification or additional records.
Dispute and Closeout – Organizations may dispute findings before final decisions are made.

⚠️ Real-world example: If a provider billed for treating hypertension, but the medical record lacks documentation of the diagnosis and care plan, it could trigger a repayment demand.

Maintaining well-organized, accurate, and easily accessible records is critical to managing this process smoothly.

Leveraging Technology to Stay Ahead

As CMS expands its use of AI and advanced analytics to identify high-risk plans and outlier data, healthcare organizations are following suit. Technology is no longer optional—it’s a strategic advantage in audit readiness.

How technology supports RADV audit readiness:

AI-powered tools can flag high-risk diagnosis codes
Data analytics platforms help detect documentation gaps before audits
Audit management software simplifies record retrieval and submission workflows

By incorporating these tools into your compliance strategy, you can proactively address issues and reduce the risk of unfavorable audit outcomes.

Expert insight: Investing in the right technology not only improves compliance but also boosts coding accuracy and operational efficiency.

Actionable Steps to Prepare for RADV Audits

Preparation is your best defense. Whether you’re undergoing an audit now or anticipating one in the future, establishing a strong compliance framework is essential.

Steps healthcare organizations should take include:

Form a multidisciplinary audit response team including compliance, HIM, and coding professionals
Perform routine internal audits to assess risk and flag inaccuracies
Provide regular staff training on proper coding and documentation practices
Maintain complete and accessible medical records to support all billed diagnoses
Implement a dispute resolution protocol for addressing audit findings

Adopt technology tools to support data validation and reporting accuracy

Conclusion: Proactive Compliance Is Key

RADV audits are no longer a rare occurrence—they’re an ongoing reality for every Medicare Advantage plan. As CMS continues to tighten its oversight, healthcare organizations must respond with stronger internal controls, smarter use of technology, and more strategic audit preparation.

By understanding the full scope of RADV audits and taking proactive steps, healthcare compliance professionals can protect their organizations from financial risk, regulatory penalties, and reputational harm. Accurate documentation isn’t just a box to check—it’s the backbone of ethical, compliant, and sustainable healthcare delivery.