How Medicare Advantage Plans Can Prepare for Increased RADV Audits

If your head is spinning with the recent updates coming out of The Centers of Medicare & Medicaid Services (CMS) regarding risk adjustment data validation (RADV), you are not alone. 

CMS recently announced sweeping changes to RADV audits aimed at increasing oversight and accelerating enforcement in the Medicare Advantage (MA) program. By investing additional resources to fast-track audits for payment years 2018-2024, they are looking to complete the existing backlog of audits by early 2026.

The importance of RADV audits

RADV audits are CMS’s primary tool for validating the accuracy of diagnosis codes submitted by MA plans. Since MA plans receive higher payments for members with more complex health conditions, CMS uses RADV audits to ensure the submitted conditions are supported by documentation in the patient’s medical record.

In the RADV Final Rule that was published in 2023, CMS confirmed the use of extrapolation starting with the 2018 audit year. This means that CMS extrapolates findings from a sample of enrollees across a plan’s entire contract population. The impact?

• A single unsupported diagnosis code in a small sample could lead to millions in overpayment recovery. For example, if CMS finds that 5 out of 100 audited member records were improperly coded, they project that error rate across all members in the plan or subset being audited.
• Extrapolated overpayments can span years of past payments—now up to six years, with CMS’s expanded lookback!
• Plans have limited time to retrieve and submit complete medical records after receiving a RADV audit notice. Records must support each diagnosis submitted for risk adjustment. If the documentation doesn’t support the code, it’s marked an error.

RADV audits are no longer a compliance formality, payers face significant financial and operational impact without a solid plan in place.

Keeping up with the demand for clinical data

With interoperability being where it’s at today, retrieving six years’ worth of paper, faxed, or variably structured electronic clinical documents is no easy task:

• Multiple systems: Charts may be spread across EHRs, portals, even in boxes in storage units. The time consuming task of manually searching for records is unsustainable.
• Format variability: Payers receive scanned PDFs, faxes, EHR downloads, and provider letters, making it difficult to take action under tight deadlines.  
• Compliance risk: Missing or late retrievals could trigger overpayments, penalties, or contested audit findings.

How faster, accurate chart retrieval can help

Moxe’s 100% digital chart retrieval pulls data directly from the provider EHR, packages it, and delivers it in payers’ specified format, making it immediately actionable. The benefits of working with Moxe include:

• Fast turnaround times: >90% of charts delivered within 5 business days, with many delivered within 1-3 business days. 
• Actionable, flexible output: With data delivered in standard and custom formats, payers can spend less time on configuring data.
• Broad, growing network: Our growing EHR-agnostic networks means we can connect to the providers payers want, to build the network they need.
  
• Transparent reporting: Up-to-the minute views into progress, average TAT, and completion rates, vendor delivery, to maximize efficiency.
  

You need fast, accurate clinical data. Moxe’s got you. Learn more about our chart retrieval capabilities for RADV in our overview. 

Let’s discuss your needs

We’d love to learn more about how Moxe can support your RADV strategy.

Schedule a consultation