Risk Adjustment Data Validation Audit

Acronym: RADV

RADV or Risk Adjustment Data Validation is used by the CMS to check the accuracy of the HCCs (Hierarchical Condition Categories) that are submitted by Medicare Advantage (MA) health plans for payment. CMS annually selects Medicare Advantage and PACE organizations for RADV audits.  These audits measure organization-level payment error rates related to risk adjustment data for payment recovery. CMS conducts two types of RADV audits: Annual national level audits to estimate the national MA improper payment rate Contract-level RADV audits to identify and recover improper payments from MA organizations RADV or Risk Adjustment Data Validation is used by the CMS to check the accuracy of the HCCs (Hierarchical Condition Categories) that are submitted by Medicare Advantage (MA) health plans for payment. A mock-RADV audit helps an MAO or provider group confirm reported diagnoses and identify ICD-10 coding errors. Errors in provider documentation can also be identified to prevent a negative impact on overall RAF (Risk Adjustment Factor) score, should CMS select the MAO’s contract for an actual RADV audit. Mock audit process typically follows the CMS’ audit model, but it can also deviate in significant ways. Typically, experienced and certified coders will identify specific medical records based on the high risk/high dollar factor, review physician and coding documentation for confirming reported diagnoses and identifying coding errors. “RADV audit” means, pursuant to 42 C.F.R. 422.2, a payment audit of an MAO administered by HHS and/or CMS.