The CMS RADV Final Rule marks a pivotal change for Medicare Advantage plans, reshaping how audits are conducted and how risk-adjusted payments are scrutinized. The expanded scope and intensified audit approach mean that revenue integrity now hinges on documentation precision and proactive compliance strategies. Plans that adapt quickly will not only safeguard their bottom line but also reinforce trust with regulators and members alike.
Why the Final Rule Changes the Stakes
One of the most significant shifts is the removal of the fee-for-service adjuster, which had previously limited financial exposure for health plans. Under the new structure, diagnosis codes that cannot be validated through medical records will be removed from risk score calculations—without offsetting adjustments. This raises the stakes for every HCC captured and demands airtight evidence for each coded condition.
Audit Expansion and Year-Round Readiness
With audit expansion, more contracts and larger sample sizes are subject to review, increasing the likelihood of selection. Medicare Advantage plans must move away from episodic compliance efforts and instead embed audit readiness into their operational DNA. That means routine retrospective chart reviews, targeted provider education, and pre-claim documentation validation as part of everyday workflows.
Technology’s Role in Protecting Revenue
Advanced coding and clinical documentation improvement platforms can identify high-risk charts and documentation gaps before submission. By integrating AI-driven tools that detect inconsistencies, surface missed opportunities, and prompt for clarifications, plans can reduce the risk of unsupported codes making it into claims.
Provider Engagement as a Defense Mechanism
Providers play a central role in ensuring compliance under the Final Rule. Educating them on what constitutes complete, defensible documentation—and how it aligns with HCC capture—creates a shared responsibility for audit outcomes. Practical feedback loops, such as post-visit documentation reviews, help providers refine their approach and reduce future risks.
Conclusion
The CMS RADV Final Rule has transformed audits from a periodic challenge into a constant operational consideration. Medicare Advantage plans that make compliance a built-in function, invest in technology, and align closely with providers will be best equipped to navigate the heightened scrutiny. Those that prepare now will not only withstand audit pressures but emerge stronger and more resilient in the long run.
