Spring has Sprung and so Have Audit Requests: Here’s What You Need to Know


While healthcare audits can happen all year round, there’s a notable high season for requests every spring. And when you’re already dealing with everyday administrative responsibilities like staff training, digital health information management, EMR systems and more, the time, energy and focus it takes to address audit requests can be daunting.

Audit requests can hit without much warning, but understanding the high season for different types of audit requests can help you be more prepared. Keep reading to learn more about how to best manage audit requests to remain both effective and compliant.


Typically, HEDIS audits are at their height from January to May, with Medicare Risk Adjustment audits hitting from May to the end of the year. Here’s how we break it down:

HEDIS Audits (~15% of audits)
The Healthcare Effectiveness Data and Information Set audit evaluates the quality of health plans. The audit is separated into two parts, the first of which measures a plan’s information systems abilities, and the second is related to HEDIS compliance.

Medicare Risk Adjustment audits (~85% of audits)
The purpose of the risk adjustment system is to sufficiently cover the costs of providing covered benefits for Medicare Advantage enrollees, including those with complex conditions. The Medicare Advantage risk adjustment system assigns a value or “risk score” to each beneficiary according to age, gender, health status, etc. The risk score reflects the person’s predicted health costs compared to those of an average beneficiary.


We’ve completed over a million audits at HealthMark – and we’ve never missed a deadline. Weekly meetings with vendors, a clear understanding of authorized access, and a secure platform help us to manage these requests appropriately. Here’s how it looks:

It is important to understand exactly how your audits are completed – what your partner or vendor will have access to, expected timeline for completion, etc. We encourage you to ask about HealthMark Group if you ever talk to an audit retrieval vendor – we are proud to help organizations become more efficient, compliant, and accurate when it comes to handling audit requests!

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