You got a RADV audit notification. Here's how to defend.
RADV (Risk Adjustment Data Validation) audits validate Medicare Advantage HCC coding accuracy. Findings can extrapolate to full plan membership. The first 30 days of preparation determine the audit outcome. This page covers the defense playbook.
What RADV auditors look for
Documentation supporting captured HCCs: face-to-face encounter notes, problem list entries, clinical evaluation supporting each HCC code. Auditors compare what you billed to what your documentation supports. Gaps = recoupment + extrapolation.
First 30 days: documentation pull
Pull all charts in the audit sample. For each HCC submitted, identify the supporting documentation. Flag any HCCs without clinical support. These are your exposure cases. prepare narrative explanations.
Documentation gaps you can still fix
Some documentation can be amended with addenda before audit submission. Provider attestations can clarify ambiguous documentation. Don't fabricate documentation; do clarify legitimate clinical context. Document the clarification process.
Audit response submission
Organized, paginated, indexed response packages. Each HCC labeled with supporting documentation references. Clinical narrative for complex cases. Cover letter explaining methodology. Auditors process organized submissions more favorably than disorganized ones.
Post-audit appeal
Initial findings are not final. Strong appeals can reverse significant recoupment. Clinical evidence + interpretation arguments matter. Don't accept first findings without review.
Free RADV audit defense consultation
Same-week consultation for active RADV audit notifications. ASP-RCM senior partners with RADV defense experience walk your audit specifics + recommend defense strategy. No obligation.
Don't wait. Get a senior partner on this.
ASP-RCM senior partners do same-day consultations on operational distress situations. 30 minutes. No SDR triage. Diagnostic conversation. You leave with a plan whether or not you engage us further.