CMS has made one thing clear: RADV audits are no longer occasional events—they are becoming a standard expectation.
In episode six of Care Decoded, host Mark McKeown sits down with Colleen Gianatasio, a leading expert in risk adjustment and coding compliance, to unpack what CMS’s expanded RADV strategy means for Medicare Advantage plans, provider organizations, and anyone involved in value-based care.
The message is simple: audit readiness is no longer a reactive exercise. It has to be built into how organizations operate every day.
CMS is moving toward auditing all eligible Medicare Advantage contracts on a recurring basis. That shift fundamentally changes how plans need to think about compliance.
RADV is no longer:
It is now:
For many organizations, this creates immediate pressure—not just to respond to audits, but to prove that documentation, coding, and risk adjustment processes are accurate at scale.
RADV pressure is increasing because the system itself has grown more complex.
As value-based care expands, more organizations are:
But many have not scaled their compliance infrastructure at the same pace.
Colleen highlights a critical gap: organizations often invest in growth and performance metrics, but underinvest in the systems needed to validate that performance.
The result is predictable:
One of the most important insights from episode six is this:
Many organizations still treat RADV as an event instead of a system.
That mindset leads to:
Colleen makes it clear that successful organizations take a different approach. They build audit readiness into their structure—before they ever receive a request.
RADV readiness requires coordination across the organization, not just within risk adjustment teams.
Colleen describes a model that functions more like a “SWAT team,” bringing together:
This group must be aligned on:
The goal is not just to respond to audits—but to ensure the organization is always prepared for one.
Most RADV failures are not random—they follow predictable patterns.
Common issues include:
Unsupported diagnoses
Conditions are documented without sufficient clinical evidence.
Carry-forward errors
Diagnoses are copied forward year over year without validation.
Vague documentation
Notes lack specificity or clarity needed to support coding.
Provider knowledge gaps
Clinicians are not fully aligned with coding requirements, especially around documentation standards.
Colleen also highlights an important distinction:
coders and providers often operate with different frameworks. Coders may rely on structured rules, while providers document clinically. Bridging that gap is critical for audit success.
A major theme in episode six is the limitation of retrospective workflows.
Retrospective strategies:
More importantly, they don’t prevent errors—they only attempt to fix them.
That’s why leading organizations are shifting toward prospective approaches, where issues are addressed at the point of care.
Technology plays a central role in this transition—but only when used correctly.
Colleen and Mark emphasize that effective tools must:
AI is particularly valuable in:
The shift is not just about automation—it’s about improving the quality of inputs before they reach CMS.
For organizations navigating RADV changes, the priorities are clear:
Colleen reinforces a key principle:
If you focus on accuracy, the rest follows.
That includes:
A RADV (Risk Adjustment Data Validation) audit is a CMS review process that verifies whether diagnoses submitted by health plans are supported by medical record documentation.
CMS is expanding RADV audits to improve payment accuracy, reduce unsupported diagnoses, and ensure that risk adjustment reflects true patient complexity.
The most common failures include unsupported diagnoses, copied documentation, vague clinical notes, and lack of specificity in coding.
Plans can prepare by improving documentation accuracy, investing in provider education, strengthening compliance workflows, and adopting prospective tools that catch issues early.
Contact Inferscience to learn about our RADV-readiness solutions and more.
