How to Lower Your Risk During a RADV Audit

Risk adjustment has come a long way these past few years. What was once a siloed department deep in Government Programs has turned into an integrated enterprise-wide approach. The evolution of what defines risk adjustment has been transformational for a health plan and created many synergies throughout the organization. Along with the advancement health plans have been making, the Centers for Medicare & Medicaid Services (CMS) has been close behind.

Risk adjustment has been a hot topic the past few months. The proposed 2019 Call Letter contained an abundance of potential changes impacting the model, calculation, and financial impact of risk adjustment. CMS has been making great strides to ensure the Medicare Advantage (MA) risk adjustment models are defining the risk of the enrollee appropriately, additionally adjusting data submission deadlines due to unforeseen occurrences over the past few months as outlined in a recent Health Plan Management System (HPMS) memo released mid-February. The memo adjusts the deadline for Risk Adjustment Processing System (RAPS) and Encounter Data Processing System (EDPS) for specific dates of service. In addition to MA, the Affordable Care Act (ACA) risk adjustment model has been under great scrutiny due to recent litigation. Now more than ever, there are many moving parts associated with risk adjustment. Staying connected with the changes to understand the current and future state impacts is critical. Awareness and understanding of impacts allow issuers stability to provide optimal benefits and quality care to members.

Now is the time of year CMS is looking to begin selection for the MA Risk Adjustment Data Validation (RADV) audits, and health plans are asking themselves two questions:

  1. Are we prepared for a RADV audit if we are selected?
  2. How will we do?

While an audit is never the most enjoyable process, there are things health plans can do to be ready for what’s ahead.

Prepare: Planning for an audit is not a last-minute agenda item. Rather, a RADV readiness plan and supporting vendors should be selected well in advance of a potential audit. It is important for impacted departments to have clear insight into their accountabilities and timeline for delivery.

Risk Avoidance: Auditing will always be a part of the health insurance industry. There is no changing that, but there are controls that can be put into place to decrease your risk exposure during an audit. Health plans need to effectively take a stance on operational processes impacting risk adjustment to implement and enforce the diligence needed to carry out the processes.

Financial: Audits are performed by CMS to ensure health plans are not being compensated for diagnoses that are not adequately supported. Due to the risk of audits and ensuring payment accuracy, a strong risk adjustment accrual and reserve process must be in place.

Need more insight? Attend my workshop at the Gorman Health Group Forum in April.

For assistance with understanding and/or establishing these processes and the impacts for proposed requirements contact me at and join me at the Gorman Health Group 2018 Forum and my pre-conference risk adjustment workshop where we will highlight core components to establish a compliant program. This session will be a deep dive into the following:

  • Organizational structure and operational efficiencies
  • Models established and financial implications
  • Understanding and preparing for a Risk Adjustment Data Validation (RADV)
  • Basics around Risk Adjustment HCC Coding
  • Establishing compliant Coding practices

If you haven’t had a chance to review the new sessions we have added for this event, download our agenda here.




Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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Jessica Smith
Jessica Smith

Jessica Smith is Vice President of Healthcare Analytics & Risk Adjustment Solutions at Gorman Health Group (GHG). In this role, she is responsible for the execution and oversight of risk adjustment consulting services for managed care, provider practice, and commercial market clients, and leading and integrating cross-functional teams to ensure superior performance outcomes related to risk adjustment operations. Read more

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