In this episode of Compliance Deconstructed, hosts Jessica Zeff, Lorie Davis, and Elvan Baker take a deep dive into the world of Risk Adjustment Data Validation (RADV) audits. These audits have become an increasingly high-stakes area of focus for healthcare compliance professionals navigating today’s regulatory landscape and this conversation will help you understand them on a deeper level.

Throughout this episode, your hosts cover the purpose and impact of RADV audits, including how CMS uses them to ensure billing accuracy and recover overpayments. With annual audits now planned for every Medicare Advantage plan, the pressure on healthcare organizations to maintain accurate documentation has never been greater.

You’ll also learn how RADV audits are conducted, from record sampling to final closeout meetings, and why internal review and proactive documentation are vital. Jessica, Lorie, and Levan also explore the real-world challenges of responding to multiple audits at once, highlighting strategies to stay ahead of the curve.

Additionally, this episode looks at how emerging technologies like AI and data analytics can streamline the audit process. By leveraging the right tools and team, organizations can better manage risk, reduce financial exposure, and maintain compliance in a rapidly evolving environment.

Key Takeaways:

• RADV audits are used by CMS to validate diagnosis coding and ensure proper reimbursement.
• The audit scope has expanded significantly, now including all Medicare Advantage plans annually.
• Inaccurate coding can lead to major financial recoupments and increased compliance risk.
• The audit process includes multiple phases, from sample selection to dispute resolution.
• AI and advanced analytics can help identify vulnerabilities and improve audit readiness.
• Proactive planning, training, and documentation are critical to navigating RADV audits successfully.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.