Few phrases strike more fear into a Medicare Advantage Organization (MAO) than: “You’ve been selected for a Risk Adjustment Data Validation (RADV) audit.” Now imagine hearing those words with only eight weeks left until the deadline.
That was the situation one health plan faced earlier this year when it discovered, without fanfare, that the organization had been selected for the Payment Year 2018 RADV audit. The notification had been missed, and now the clock was ticking.
For context, MAOs receive a monthly payment from the Centers for Medicare & Medicaid Services (CMS) based on their members diagnoses in the form of a risk adjustment payment. RADV audits are CMS’ way of verifying that diagnosis codes submitted for risk adjustment are supported by documentation. If plans don’t perform well in the audit, they could face significant extrapolated repayment penalties according to the RADV final rule.
First-time nerves. No time to spare.
This was the plan’s first-ever RADV audit. No playbook. No institutional memory. Just a tight deadline and a long to-do list. The team had less than two months to gather medical records, reconcile diagnosis codes, validate physician signatures, and submit their documentation to CMS through their Centralized Data Abstraction Tool (CDAT).
Many teams might have turned to spreadsheets, late nights, and a lot of caffeine. But this plan had recently adopted a purpose-built RADV audit tool, a software platform designed to streamline the audit response process from start to finish.
From chaos to command center
The tool’s intuitive workflows brought comfort and structure by automatically surfacing all risk adjustable diagnoses hidden within the disorganized mess of medical records. AI-driven features automatically surfaced each diagnosis and prepopulated details like the ICD-10 and hierarchical condition codes (HCCs), note types, and dates of service, so the team could jump straight into analyzing data.
Instead of juggling documentation across systems and spreadsheets, the team worked within a centralized command center: member by member, chart by chart, code by code. This consolidated view allowed everyone, from coders to compliance officers, to monitor audit progression in real time. With full visibility into chart status, workflow bottlenecks, and documentation readiness, the entire organization could stay aligned and confident as the submission deadline approached.
The RADV audit tool was designed with CMS audit requirements in mind. The tool supports signature validation, ICD-10-CM accuracy, and even assigned confidence scores to each diagnosis. This aided the team in prioritizing their submissions for the highest possible validation rate.
Accuracy on a deadline
Despite the compressed timeline, the plan completed the audit by the deadline. As a result of built-in QA checkpoints and confidence scoring, the team had a clear understanding of how their charts would likely perform in the audit.
And here’s the kicker—while this was their first RADV audit, by the end of the experience they were navigating like seasoned pros, relying on the tool’s built-in guidance to steer them through to the finish line.
If you’re leading a risk adjustment team and thinking, “This could’ve been us,” you’re not alone. Any MAO, big or small, can get pulled into a RADV audit. And when it happens, it’s a big deal. With tight timelines and the threat of extrapolated repayments, the stakes couldn’t be higher.
A new era of audit readiness
We’re entering a new era of RADV audits, one where preparation means more than just scrambling with spreadsheets. In today’s high-stakes regulatory environment, true audit readiness starts with smart, purpose-built technology designed specifically for CMS compliance. It’s not just a tool, it’s your peace of mind when the audit letter arrives.
Our solution takes the complexity out of the audit process. From day one, you’ll have a streamlined, efficient system that anticipates your needs and eliminates last-minute panic by turning even the tightest of deadlines into a smooth success. Audit success doesn’t happen by chance. It starts with having the right tools, right now.
Click here to learn more about the Wolters Kluwer Risk Adjustment Solution, the Health Language Coder Workbench, and the capabilities of our Regulatory Audit Module. Also make sure to swing by our booth #308 at the upcoming RISE Risk Adjustment Forum, May 13-15th in Westlake Village, Calif., to say hello and learn how we can help you prepare for the next, inevitable audit!