Your One-Stop Guide to RADV Audits

Because acronyms are fun—especially when they come with deadlines.

HIM professionals are no strangers to audits, but when you’re in the weeds managing deadline after deadline, they can start to look like alphabet soup. (HEDIS, MAC, RAC, QIO… you get the idea.) With another major audit cycle upon us, we’re shining the light on RADV audits and sharing what you can do to lessen the impact on your team when deadlines are right around the corner.

Risk Adjustment Data Validation (RADV) audits are overseen by the Centers for Medicare & Medicaid Services (CMS) to make sure the diagnosis codes that impact risk scores are accurately reported. You can think of RADV audits as the IRS for Medicare Advantage Organizations (MAOs). Similar to how the IRS validates our tax information every year, CMS uses RADV audits to validate the documentation integrity of patient diagnoses and risk adjustment scores under Medicare Advantage plans.

CMS uses RADV to audit health plans, and in turn, health plans rely on providers and HIM departments to supply the right information. While RADV audits impact many roles in healthcare, HIM teams are the unsung heroes when it comes to making sure these audits are done accurately and on time.

Keep reading to learn how your team can adopt strategies to avoid a last-minute scramble and face these audits head-on.

What is a RADV audit?

Let’s break it down: RADV is a CMS-led audit process that evaluates the accuracy of diagnosis codes submitted by Medicare Advantage plans. The purpose of this audit is to ensure that everything reported is validated within the patient’s own medical record. In other words, CMS is checking the receipts.

Why does this matter? Because those diagnosis codes aren’t just checkboxes on a patient’s medical record—they’re directly tied to risk scores, which impact reimbursement rates from Medicare Advantage plans. If the codes don’t reflect the patient’s actual condition, or if the documentation doesn’t support what’s reported in the audit, CMS could demand repayment.

Here’s what CMS looks for in RADV audits:

• Diagnosis codes that map to Hierarchical Condition Categories (HCCs)
• Clinical documentation that supports those diagnoses
• Timeliness and specificity of documentation
• Alignment between what’s billed and what’s in the chart

RADV Audit Process

If you’ve ever been hit with an audit of any kind, you know it can be a lengthy process. With documentation hurdles, data validation checkpoints and a whole lot of admin-heavy lifting along the way, the race to the end can start to feel like an obstacle course.

At a high level, the RADV process typically looks like this:

1. CMS selects the sample and notifies MAOs
2. Requests for medical records go out
3. Medical records are reviewed and abstracted
4. Data is submitted on or before the deadline
5. Patient records are reviewed to validate risk scores
6. Follow-ups and appeals are conducted on an as-needed basis

Depending on the scope and the size of the sample, it can take several months to complete a RADV audit, eating up valuable time and resources across departments from HIM to compliance to finance.

RADV audits are a heavy lift, no matter how experienced your team is. But with the right tools and workflows in place, there are ways to reduce the burden and streamline the process.

How Often are RADV Audits Done?

Each year, CMS kicks off a new audit cycle focused on data from previous payment years. So if you’re in HIM, there’s always a RADV audit either wrapping up, about to begin or just looming around the corner.

• Spring through summer: CMS notifies MAOs and begins the sample selection process
• Late summer through early fall: Healthcare organizations receive enrollee samples and begin the hunt for supporting medical records
• Fall to winter: HIM teams and coding partners are heads-down gathering, reviewing, abstracting and submitting documentation
• Early the following year: CMS conducts reviews, issues findings and begins the appeals process

This timeline doesn’t mean HIM teams need to be in “RADV mode” all year, but it does mean that a proactive, year-round strategy is key for delivering the audits on time—while keeping your sanity intact!

Challenges with Tackling RADV Audits on Your Own

For most HIM teams, you’re already managing daily requests, patient record releases, documentation improvement efforts and compliance monitoring—and on top of that, you’re being asked to track down, validate and submit potentially hundreds of medical records on a tight deadline. That’s a lot.

Pain points that HIM teams face when tackling RADV audits in-house without any additional support usually include:

• Crushing administrative burden: Collecting, reviewing, abstracting and submitting the required documentation for RADV audits takes time—and a lot of it. It often means diverting staff from their day-to-day responsibilities, which can create bottlenecks elsewhere in the department.
• Massive volumes of data: These audits aren’t just about a few records here and there. CMS might request documentation for dozens or even hundreds of enrollees, each requiring detailed, date-specific clinical documentation to support multiple diagnoses.
• Staffing shortages and bandwidth strains: HIM teams are already stretched thin in many organizations. Adding the weight of a RADV audit without additional resources can lead to burnout, delays or missed documentation that could impact financial outcomes.
• Disruptions to patient service: When HIM professionals are pulled into RADV projects, there’s a risk that other patient-facing services fall behind.

How Can My Team Prepare for RADV Audits?

If reading about the in-house RADV audit grind made your stress levels spike, you’re not alone. The truth is, more and more HIM teams are realizing they don’t have to go it alone—and they shouldn’t have to.

Here are a few ways HIM departments can stay audit-ready:

• Build audit-readiness into daily workflows. Encourage clinicians to document with precision and clarity, knowing their notes may be reviewed at any point down the line.
• Keep your release of information processes sharp. Efficient, consistent retrieval and delivery of medical records is half the battle during audit season.
• Collaborate across departments. Finance, compliance and HIM need to stay aligned on expectations and timelines.
• Use technology and trusted partners to your advantage. Whether it’s an advanced release of information platform or an experienced audit response team, having the right support can save you time—and headaches.

Because RADV audits follow a predictable timeline, the most successful HIM teams treat preparation as an ongoing habit, not a last-minute scramble. By staying ahead of the curve, you won’t just survive RADV season; you’ll own it.

Weighing Your Options? Let’s Chat

Let’s face it—audits hit HIM teams hard, and trying to juggle audits on top of your everyday HIM responsibilities can feel like a game of whack-a-mole. That’s why so many healthcare organizations are opting to get more outside support for RADV audits from specialized release of information partners.

But outsourcing doesn’t mean handing over the reins. It means bringing in a team of trained professionals (or in HealthMark’s case, certified release of information specialists) who live and breathe audits so your staff can stay focused on what they do best; supporting patient care.

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