Preparing for a RADV audit? Follow these six steps.

In the ever-evolving landscape of healthcare compliance, the Risk Adjustment Data Validation (RADV) audit stands out as a critical process that demands meticulous preparation. Being proactive and implementing a strategic approach can not only streamline the audit process but also ensure your organization’s success. Let’s explore the six steps organizations should remember to successfully prepare for a RADV audit.

1) Understand RADV requirements

The first step in preparing for a RADV audit is to have a comprehensive understanding of the requirements. Familiarize yourself with the RADV guidelines, protocols, and any recent updates. This includes staying informed about the CMS (Centers for Medicare & Medicaid Services) regulations and documentation requirements. The more intimately you know the rules, the better positioned your organization will be to meet and exceed compliance standards.

2) Conduct internal audits

Performing internal audits is a proactive measure to identify and address potential issues before the RADV audit. Regularly review your coding practices, documentation accuracy, and submission processes. This internal assessment will not only help in identifying any gaps but will also serve as a valuable opportunity to rectify discrepancies and enhance overall coding accuracy.

3) Ensure accurate documentation

Accurate and detailed documentation is the backbone of a successful RADV audit. Providers must ensure that medical records accurately reflect the patient’s health status, including all relevant diagnoses. Implement a robust documentation improvement program to address any shortcomings and educate staff on the importance of thorough and precise documentation.

4) Invest in training and education

Education is key to compliance. Regularly train your coding and documentation teams to stay abreast of the latest coding guidelines and RADV audit requirements. Investing in ongoing education not only ensures that your team is well-informed but also helps in creating a culture of compliance within your organization. In addition to traditional HCC coding education methods, new engaging tools are now available that significantly enhance knowledge retention compared to traditional approaches. 

One such tool, the DoctusTech mobile app, stands out as a premier provider of HCC coding education in this field. Clinicians can utilize the app to enhance their knowledge and stay current on HCC coding. Schedule a demonstration to discover how DoctusTech supports healthcare providers in training their clinicians.

5) Implement technology solutions

Leverage technology to streamline your RADV audit preparation. Implement advanced coding and documentation tools that can identify potential discrepancies, errors, or missing information. Automated solutions can significantly reduce the risk of oversights and enhance the overall efficiency of your coding and documentation processes.

DoctusTech is a groundbreaking tech solution that transforms HCC code capture. This platform simplifies the process for clinicians to precisely record HCC codes within their EMR for each patient. With DoctusTech HCC 360, EMR workflows are streamlined by consolidating external data sources and presenting information to clinicians in real time as they document progress notes. Integration with major EMRs is seamless. To discover more about this innovative product, schedule a demo today.

6) Establish a communication plan:

Effective communication is vital during the RADV audit preparation. Establish a clear communication plan within your organization to ensure that all relevant stakeholders are aware of their roles and responsibilities. Foster open lines of communication between coding teams, documentation specialists, and leadership. This collaborative approach will help in addressing challenges promptly and ensuring a cohesive effort toward RADV audit success.

In conclusion, considering how to prepare for a RADV audit requires a proactive, strategic approach. By understanding the requirements, conducting internal audits, ensuring accurate documentation, investing in training, leveraging technology, and establishing effective communication, your organization can navigate the complexities of the audit process with confidence. Stay vigilant, stay compliant, and pave the way for a successful RADV audit.

What is the CMS HCC Risk Adjustment Model?

The CMS, or Centers for Medicare & Medicaid Services, developed the HCC Risk Adjustment Model to determine Medicare Advantage (MA) plan payments, based on the expected healthcare costs of plan enrolees. HCC stands for Hierarchical Condition Categories, which are groups of medical conditions that share similar expected costs of treatment.

Since its inception in 2004, the CMS HCC Risk Adjustment Model assigns each MA enrolee a risk score based on their demographic information – such as age and gender – their medical conditions, and the severity of those conditions. The risk score is calculated by first assigning HCCs to each enrolee based on their medical diagnoses, then applying a weight to each HCC based on the expected cost of treatment. These weights are then added up to determine the enrolees’ overall risk score.

The CMS HCC Risk Adjustment Model is designed to account for differences in the health status and expected costs of care among MA enrolees, and to ensure that MA plans are adequately compensated for the medical needs of their enrolees. The risk adjustment methodology is used to adjust payments made to MA plans based on the enrolee’s risk score, with higher risk scores resulting in higher payments to the MA plan.

The CMS HCC Risk Adjustment Model is updated annually to reflect changes in the prevalence and costs of medical conditions, as well as changes in the coding and classification systems used to identify medical diagnoses.

What is a RAF score? 

The Risk Adjustment Factor (RAF) score is a measure used to adjust the payment for healthcare services based on the health status and expected medical costs of the patient. The RAF score is typically used in the context of Medicare Advantage (MA) plans, which are a type of health insurance offered by private companies that contract with Medicare to provide Medicare benefits to eligible individuals.

The RAF score is calculated using a formula that takes into account the patient’s demographic information, such as age and gender, as well as their medical conditions and the severity of those conditions. The formula assigns a weight to each medical condition based on its expected cost of treatment. The weights are then added up to determine the patient’s overall RAF score.

So a patient has a RAF of 1.5 may have a 0.6 from demographics, a 0.3 for diabetes, and 0.6 from COPD. 

The RAF score is used to adjust the payment made by Medicare to the MA plan for each patient. Patients with higher RAF scores are considered more expensive to treat, and the MA plan will receive a higher payment to cover the expected costs of care. This helps to ensure that MA plans are adequately compensated for the medical needs of their patients, and that patients with more complex health conditions receive appropriate care.

How do HCCs relate to it?

Each year, Medicare calculates an amount of money that will be paid per member per month (PMPM).  This same base rate is paid out for every patient, regardless of what services were done.  This base rate is then multiplied by the patient’s RAF score so that more money is payed out to take care of patients with a high RAF (sicker patients) than those with a low RAF (healthier patients).  

If a CMS patient has a high RAF, they he/she is expected to get extensive medical care, clinicians who enrol these are reimbursed more than those who have low RAFs. The additional reimbursement amounts for patients who qualify will not be paid to organizations that do not properly or completely document HCC codes as incorrectly documented codes do not add to the RAF score.

To know more about HCC coding and how to improve it, you can refer to our blog on ‘How to improve HCC coding and avoid risks.’

ACO REACH Model Replaces GDCP (DCE) Model – But What Really Changed?


CMS recently unveiled their replacement for the Direct Contracting Model (DCE), renamed now as the ACO REACH Model. Many of the original Direct Contracting Model tenets will remain the same, with a few significant changes announced.


From heightened scrutiny on up-coding and documentation accuracy to improved Access and Equitythe new model looks to improve upon DCE without replacing it entirely.


Download the full CMS webinar presentation deck, and read our interpretation of the new guidelines.

Access the full report below.