RADV Audits Are Coming for Your Risk Scores. Is Your Documentation Ready to Defend Itself?

Lavette Minn

6/20/20262 min read

Every Medicare Advantage plan operating today has RAF scores sitting on its books that someone, eventually, will have to defend. That is not a hypothetical. CMS has made RADV audits a permanent fixture of risk adjustment, and the agency is no longer treating audit findings as isolated errors. It is extrapolating them across entire contracts.

That means one weak chart, one unsupported HCC, one documentation gap that should have been caught internally, can turn into a repayment demand worth millions. I have spent over twenty years inside this exact problem, and I can tell you the organizations that get hurt the worst are not the ones with bad coders. They are the ones with no one checking the intersection of documentation, coding, and compliance before CMS does it for them.

Why "We Have a Compliance Team" Is Not the Same as "We Are Audit Ready"

Most health plans and provider groups already have compliance staff, coding teams, and CDI specialists. I am not telling you that you lack expertise internally. I am telling you that expertise sitting in separate departments is not the same as a coordinated audit defense.

Coders capture what is documented. CDI teams chase documentation improvement. Compliance reviews policy adherence. Rarely does anyone sit across all three and ask the question CMS will actually ask during a RADV audit: can you prove, with the medical record alone, that this HCC was valid on the date of service?

If the honest answer is "probably" instead of "yes," you already have exposure.

Where V28 Changed the Math

The shift to the V28 HCC model did not just reshuffle categories. It tightened the relationship between documentation specificity and RAF accuracy. Conditions that used to support a code under V24 logic may not support the same code under V28 without more precise clinical language.

If your coding team has not been retrained on these distinctions, and if your CDI queries have not been updated to reflect them, you are likely carrying RAF scores today that were accurate under the old model and are no longer defensible under the new one. That gap does not announce itself. It surfaces during an audit, when it is too late to fix.

What Audit Readiness Actually Looks Like

Audit readiness is not a binder of policies. It is the ability to pull a chart, trace the code back to a clinically supported diagnosis, and show the documentation trail that justifies it, every time, without scrambling.

That requires a few things most organizations have not built:

A standardized internal validation process that mirrors what a RADV auditor will actually look for, not just what compliance assumes they will look for.

A feedback loop between coding findings and CDI queries, so documentation gaps get corrected at the source instead of being flagged after the fact.

A clear, defensible rationale for every AI-assisted code recommendation, because "the software suggested it" is not an answer CMS will accept.

This Is the Work I Do

I help health plans, provider groups, and RCM organizations build exactly this kind of audit-ready infrastructure before CMS comes knocking. That means reviewing your current RAF capture practices against V28 requirements, identifying where your documentation trail has gaps, and building the cross-functional alignment between coding, CDI, and compliance that most internal teams do not have the bandwidth or the outside perspective to build themselves.

If you are sitting on RAF scores you have not stress tested against an actual audit standard, now is the time, not after you receive the audit notice.

Lavette Minn is an AI in Healthcare and Revenue Integrity Advisor with over 20 years of experience in risk adjustment, medical coding, and audit readiness strategy.

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