Medicare Advantage (MA) audits are on the horizon, and with them come increased scrutiny of how diagnoses are documented and reported.
Understanding the Audit Landscape
Every payment year, Risk Adjustment Data Validation (RADV) audits are conducted by the Centers for Medicare and Medicaid Services (CMS) to verify that diagnoses submitted by MA plans for risk adjustment are supported by medical records. If a diagnosis cannot be validated through the medical record, it is removed from the risk score, which may result in repayment demands from CMS.
Currently, CMS is several years behind in completing these audits. To address this backlog, CMS introduced a plan to complete all remaining audits by 2026. Key elements of the plan include:
- Enhanced Technology: CMS will deploy advanced systems to review records and flag unsupported diagnoses.
- Workforce Expansion: CMS will grow its team of medical coders from 40 to approximately 2,000.
- Increased Audit Volume: CMS is expanding RADV audits to all eligible MA plans every year. By using technology, CMS will increase its review scope from 35 medical records per plan to between 35 and 200 records per plan, depending on the plan size.
The implications are substantial for MA plans. Providers must strengthen documentation now to avoid costly compliance issues in the future.
Key Areas for Audit Readiness
- Documentation Quality: Medical records are the primary defense in a RADV audit. To ensure documentation supports the specificity and severity of reported diagnoses:
- link diagnoses to clinical findings and treatment plans.
- use the most specific ICD-10 codes available.
- document all chronic and active conditions that impact patient care during each encounter.
- ensure documentation reflects the patient’s condition on the date of service.
- Coding Accuracy: Expect closer scrutiny of diagnosis coding for risk-adjusted conditions. To prepare, review coding practices and ensure alignment with ICD-10-CM guidelines. Pay special attention to chronic diseases that impact risk scores (diabetes with complications, heart failure, CKD, etc.).
- Staff Training & Education: Both clinical and administrative staff should understand the connection between documentation, quality, and compliance. Consider creating internal guidelines that address frequent audit issues and reinforce common gaps in documentation and coding accuracy.
Practical Steps to be Audit-Ready
Preparation should be a continuous process, not a last-minute scramble. Consistent documentation standards, regular training, and periodic internal audits will keep your practice aligned with CMS guidelines.
- Conduct Internal Documentation Reviews: Proactive chart audits can help identify potential issues before external audits. Work with internal compliance teams to:
- review a sample of patient charts for coding accuracy.
- provide feedback and education to providers.
- track and correct recurring documentation errors.
- Engage Care Teams: Nurses, medical assistants, and care coordinators play a role in ensuring accurate patient records. Encourage care teams to:
- gather complete patient histories.
- update medication lists and review changes at each visit.
- flag care gaps that may reveal undocumented conditions.
- Monitor Compliance Metrics: Track documentation completion rates, coding accuracy, and audit findings. Use these metrics to spot trends, address weaknesses, and improve measures.
The expanded MA audit plan marks a lasting change in CMS oversight. For providers, this is not just a compliance checkpoint, it is an opportunity to strengthen documentation practices, improve patient care, and protect reimbursement. The providers who prepare now will navigate audits with confidence, while those who wait may face costly corrections.
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