In the high-stakes arena of risk adjustment, the Department of Health and Human Services (HHS) recently published results from the 2023 benefit year HHS-RADV (Risk Adjustment Data Validation) audit. While these results apply to the HHS risk adjustment program, the findings hold important lessons for anyone involved in Medicare Advantage (MA) and CMS-HCC coding. 

 

The persistent documentation gaps uncovered by HHS are the same cracks that CMS looks for when reviewing Medicare Advantage risk scores. 

 

So what did the 2023 RADV uncover? Let’s take a look at the key findings.

 

Key findings from the 2023 RADV results

 

The 2023 RADV results paint a clear picture of where the cracks in documentation remain.

 

Broader participation, higher stakes

 

In 2023, HHS expanded its audit to include 471 of 596 issuers with risk-adjustment plans, a jump from 463 of 606 in 2022. That means nearly 80% of issuers faced audit scrutiny last year. The trend is clear: broader oversight is becoming the norm.

Persistently miscoded HCCs (Hierarchical Condition Categories)

 

Certain conditions remain top audit targets. HHS found that the most frequently invalidated codes were:

• • Diabetes with chronic complications 
  • Specified heart arrhythmias 
  • COPD / bronchiectasis 

 

These three diagnoses exist in both models, and they continue to trip up coders and providers due to ambiguous documentation, overlooked guidance, or coder inexperience. For MA organizations, the signal is clear: if HHS is flagging them, CMS will too.

Adjustments to risk adjustment transfers

 

Where high error rates were found, HHS adjusted plan liability risk scores and transfers. Issuers with error-prone coding faced reduced payments or retroactive charges, while others saw upward adjustments. Medicare Advantage plans should expect similar mechanics under CMS RADV, especially as oversight expands.

 

And CMS isn’t letting these errors slide. The agency’s response has been to double down, expanding audits and deploying new tools to catch unsupported codes even faster.

 

Rising scrutiny: Why 2025 RADV audits are a game-changer

 

If the 2023 audit was a warning, 2025 is the storm on the horizon. CMS isn’t just adjusting; it’s escalating. Recent announcements confirm that:

 

• • All eligible Medicare Advantage plans will be audited annually, up from just around 60 plans per year.
  • CMS aims to clear its audit backlog for Payment Years 2018 through 2024 by early 2026.
  • The volume of records per audit is expanding, potentially up to 200 records per plan—amplifying documentation demands.
  • CMS is deploying AI and machine learning tools and scaling its workforce from dozens to nearly 2,000 coders by September 2025.

 

For providers, this means the days of hoping your health plan’s audit will cover you are over. CMS is coming with sharper tools, more auditors, and a longer memory. The backlog of audits from 2018 through 2024 will be closed by 2026. That’s nearly a decade of risk converging all at once.

 

These changes dramatically heighten the risk profile for both Medicare Advantage Organizations and at-risk providers, particularly those in shared-risk or value-based arrangements, as they face potential claw-backs on prior years and reduced future income.

 

Why the tougher stance? Because the same errors keep showing up year after year. The most common miscoding pitfalls tell the story.

 

Common miscoding pitfalls and their roots

 

Every unsupported diagnosis CMS flags in a RADV audit has a backstory. Rarely is it outright fraud; more often, it’s the small cracks in documentation and coding that add up. HHS-RADV flagged the same root causes that CMS auditors see: 

 

1. 1. Vague consultation documentation
      

      Diagnosis codes must be fully supported by clear, dated, and signed clinical notes, not just shorthand terms or unexplained abbreviations.

   2. Failure to follow coding clinic guidance
      

      Even when guidance exists —such as for Diabetes with Chronic Complications— misunderstanding or ignoring it leads to repeated errors.

   3. Overlooked HCC aggregations
      

      Coders sometimes fail to collapse overlapping conditions appropriately (when applicable), inflating chronic condition counts.

   4. Coder inexperience
      

      Coding staff unfamiliar with CMS requirements or nuanced ICD‑10 conventions continue to make misclassification errors.

In isolation, these missteps might look like small clerical slips. But RADV audits magnify them, turning documentation shortcuts into revenue risk. For providers and health plans, the lesson is clear: unless the roots of miscoding are addressed through education, workflow support, and real-time feedback, the same mistakes will keep surfacing, and the financial exposure will only grow.

 

On the surface, these may look like minor slips. But under RADV’s microscope, each miscode can snowball into clawbacks, strained contracts, and compliance risk.

 

Downstream impact on providers: What’s at stake

 

For providers, the real shock of a RADV audit often doesn’t come from the initial findings. It comes from the ripple effects. What appears to be a single unsupported diagnosis on paper can quickly escalate into financial, operational, and even legal consequences. Let’s dig deeper on what’s at stake:

 

• • Financial exposure through shared-risk contracts. Providers may inadvertently trigger overpayment recoupments if plans are audited and found to be outliers.
• • Administrative burden from documentation requests. With audit scopes expanding, clinics and hospitals face heavier demands for chart retrieval and note validation.
• • Contract renegotiations and trust erosion. Payers may reevaluate shared-risk arrangements if documentation accuracy (and, by extension, compliance) falls short.
• • Increased liability risk. Failure to support diagnoses not only damages reimbursement but can also trigger Stark Law or False Claims Act scrutiny.

 

 

In short, RADV audits don’t just test documentation accuracy; they test the resilience of an entire organization. Providers who treat them as someone else’s problem risk discovering too late that the financial and reputational fallout lands squarely at their doorstep.

 

As CMS sharpens its audit tools and scales its oversight, providers must bolster documentation and coding defenses, and fast. The 2023 RADV data, especially around persistent miscoded HCCs like Diabetes, Arrhythmias, and COPD, reveal where coding vulnerabilities remain. Without swift intervention, the financial and contractual fallout could be severe.

 

That’s why organizations need tools that don’t just catch errors after the fact, but prevent them at the point of care.

 

Turning Documentation Into a Strength

 

The 2023 HHS-RADV results spotlight the same weak points that Medicare Advantage plans must address. For providers, the way forward isn’t chasing errors after the fact; it’s building systems that prevent them at the point of care.

 

That’s why, at DoctusTech, we build AI-powered solutions that transform documentation from a liability into an advantage:

 

• • Learning app & personalized training: Clinicians learn HCC coding in minutes, not months, with on-demand lessons tailored to their real gaps.
  • AI diagnosis assistant: Embedded in your EMR, it surfaces patient history, prompts for codes, and translates charts in real time. Less clicking, more compliance.

 

Each tool stands strong on its own, but together they create a system that protects providers from miscoding errors and audit exposure without slowing down clinical workflows.

 

Ready to protect your organization? Get a Free Demo of DoctusTech’s HCC Coding Solutions today.