RADV is no longer an occasional compliance exercise. It remains an operational reality for ACA plans and even more so for MAOs.
RADV readiness now starts long before an audit begins. With increasing audit activity and greater operational complexity, health plans need to look beyond audit response and build readiness into their everyday risk adjustment operations.
This is the focus of Pareto Intelligence’s webinar, Your RADV Game Plan: Helping Health Plans Navigate the New Era of RADV Amid Increasing Financial, Regulatory, and Operational Pressure.
The discussion examines how changes to the RADV environment are raising the stakes for health plans and explores practical ways organizations can strengthen audit readiness. From chart-chase strategy and coding quality assurance to retrieval capacity and analytics, the webinar offers a framework for improving RADV operations and real-world examples of the challenges plans face today.
What’s changing in RADV and why it matters
One of the most significant changes is the scale of CMS RADV activity.
Historically, CMS audited roughly 60 organizations annually. Now, every eligible Medicare Advantage organization may be in scope every year, with 35 to 200 members selected per H contract. At the same time, payment-year audits from 2018 through 2025 are moving forward concurrently during the RADV “catch-up” period.
Organizations operating multiple Medicare Advantage products can see substantially more audit activity, placing greater demands on teams that already support HHS-RADV, retrospective programs, prospective campaigns, concurrent initiatives, and routine risk adjustment operations.
Other changes further increase the pressure. Beginning with payment year 2020 RADV, “spontaneous” HCCs no longer offset identified potential overpayments. CMS has also reduced the number of medical records that may be submitted to validate a member/HCC from five to two.
ACA RADV has been more stable, but that doesn’t make it any less important. Poor results can still carry significant financial consequences, making strong audit readiness essential.
As presenter Kevin Beltzman puts it, “Documentation is everything.” Every submitted HCC must have sufficient medical-record support under the applicable payment year’s RADV guidelines, making documentation accuracy, encounter data completeness, and the ability to locate the right medical record even more important.
A framework for strengthening RADV readiness
Maintain: Protect core operations
Preparing for RADV cannot come at the expense of everything else.
Plans still need to execute existing risk adjustment programs and address ongoing operational gaps. When volume exceeds internal capacity, temporary or longer-term RADV vendor support for retrieval, coding, and analytics may help prevent RADV requirements from disrupting core programs.
The challenge is to avoid “robbing Peter to pay Paul” by shifting so much attention and capacity to RADV that current and future risk adjustment work begins to suffer.
Provider engagement remains critical. Results from RADV and retrospective programs can provide valuable intelligence about documentation patterns and recurring issues. Those lessons can then be turned into more targeted provider education. For example, focusing education on the specific conditions a provider has historically struggled to document completely.
Tighten controls and sharpen targeting
As RADV volumes increase, broad activity is not enough. Plans need greater precision, including
- expanding analytics to uncover additional chart opportunities
- prioritizing outreach by member and HCC
- pursuing records across multiple locations where appropriate
- quantifying outstanding or unvalidated HCCs for executive reporting.
Plans may need market-specific retrieval strategies rather than relying on a single vendor or approach across all geographies.
Mike Fertl describes analytics as “the engine of the car.” Operations still need someone to drive the process, but stronger analytics can help teams get where they need to go more quickly and efficiently.
That means starting with the broadest useful view of available data and, in the presenters’ words, “turning over every rock” to locate, review, and validate audited member HCCs.
Instead of arbitrarily limiting the number of charts to review for a targeted HCC, organizations can prioritize efforts based on claim indications, provider specialty, coding trends, and other factors,
The goal is not simply more chasing. It is smarter chasing.
The presenters recommend casting a wider net early and then refining efforts as charts come in. As Mike explains, the objective is to “set ourselves up in a great position to start and then adjust accordingly,” rather than reach the end of an audit with unvalidated HCCs and have to panic and rush.
Optimize: Build RADV readiness into the operating model
Longer term, plans may need to rethink processes that were built for a less intensive RADV environment.
Opportunities discussed during the webinar included shortening internal chart-request deadlines to allow more time to adjust strategy, tracking retrieval and coding performance year over year, monitoring net-new adds and deletes, and building or querying chart repositories to avoid unnecessary duplicate retrieval efforts.
A centralized view of previously retrieved records can be especially valuable when multiple departments request medical records for different purposes. Knowing what is already available can eliminate unnecessary chases and give RADV teams more time to focus on records that still need to be located.
The overarching message is clear: organizations should treat Medicare Advantage RADV and HHS-RADV as recurring operating requirements rather than as discrete projects.
That shift has implications far beyond the risk adjustment department. Compliance, payment integrity, quality, finance, and executive leadership all have a stake in understanding potential exposure and in ensuring teams have the processes and resources needed to respond.
What real-world RADV challenges look like
The webinar explores four scenarios that reflect issues health plans are already encountering.
Coding strategy and capacity. Bringing coding in-house can provide greater transparency and oversight, but overlapping RADV timelines can strain internal coding and QA resources. One alternative discusses was to increase internal QA for externally coded charts while preserving outside capacity for first-level reviews.
Analytics and targeting. Some plans still have invalidated or outstanding HCCs after initial retrieval and coding, with no clear pathway to identify additional records. Better use of internal and external data, historical retrieval outcomes, and specialized analytics can help teams determine the right record, provider location, and member to pursue.
Medical record retrieval. When retrieval falls behind schedule, or a RADV vendor lags, downstream activity is compressed. The webinar highlights critical activities to select the most effective outreach channel.
IVA rebuttals. Differences in how documentation requirements are interpreted can create another layer of risk. Escalating outstanding requests, reconciling submitted documentation, performing QA on every chart, and supplying additional evidence when appropriate can help prevent unfavorable outcomes.
Bottom line: Make RADV readiness continuous
The expanding audit environment makes it increasingly difficult to treat RADV as a periodic fire drill.
Health plans need to maintain core risk adjustment operations while tightening controls today and building stronger audit-readiness capabilities for tomorrow. The steps needed vary by plan, and may include strengthening analytics, improving coding and documentation oversight, or bringing in additional RADV support.
There isn’t a single solution that eliminates RADV risk. As Mike notes, “There is no silver bullet,” but the more proactive and forward-looking plans are, the better positioned they are for success across the broader risk adjustment program.
For risk adjustment and Medicare Advantage and ACA plan leaders, the questions are shifting from whether RADV will affect operations to where the greatest vulnerabilities lie and what should be done now to address them.
The on-demand webinar, Your RADV Game Plan, takes a deeper look at these challenges, recommended chart-chase approaches, and real-world scenarios to help health plans evaluate their current RADV strategy.
Watch the on-demand webinar to explore the full discussion and identify opportunities to strengthen your organization's RADV game plan.