What is a RADV audit and how does it affect providers?

A RADV audit is a Risk Adjustment Data Validation audit used by CMS to verify the accuracy of risk adjustment data submitted by Medicare Advantage plans. While audits are conducted at the plan level, the results can influence payer behavior and create downstream financial and compliance implications for providers.

How do RADV audits impact Medicare Advantage payments to providers?

RADV audits can lead to payment adjustments at the plan level, which may affect how Medicare Advantage plans manage reimbursement, contracts, and documentation expectations with providers. This can introduce new financial and operational considerations for provider organizations.

What role do providers play in RADV audit readiness?

Providers play a role in ensuring accurate clinical documentation, supporting compliance efforts, and aligning operational processes with payer requirements. Their documentation and coding practices contribute to the data used in risk adjustment and may be subject to review.

Why are RADV audits increasing provider compliance risk?

As CMS intensifies Medicare Advantage enforcement, RADV audits are prompting plans to reassess risk and oversight activities. This can lead to increased scrutiny of provider documentation, coding, and contractual obligations.

How can providers assess and respond to RADV-related risk?

Providers can evaluate contractual obligations, conduct internal risk assessments, implement auditing and monitoring processes, and align with payer expectations. These steps can help organizations understand and manage potential financial and compliance exposure tied to RADV audits.

New Webinar: “CMS Enforcement to Provider Risk: The Downstream Impact of RADV Audits”

Wednesday, April 22, 2026

11:00 am – 12:00 pm E.T.

Duration: 60 Minutes

Webinars

Series

Healthcare Regulatory Roundup

Twice each month, PYA experts discuss the latest industry developments as part of our popular Healthcare Regulatory Roundup (HCRR) webinar series. In addition to straightforward explanations of those developments and actionable guidance, attendees will be offered the chance to earn continuing professional education units in selected sessions.

As CMS intensifies Medicare Advantage enforcement, RADV audits are reshaping payer behavior and creating new financial, operational, and compliance risks for providers. This session explains what providers need to understand, anticipate, and address now.

Learning Objectives:

Understand how Medicare Advantage payments flow from CMS to MA plans to network providers, and where risk is introduced
Review the fundamentals of Medicare Advantage risk adjustment and Risk Adjustment Data Validation (RADV) audits
Identify the role of providers in compliance, clinical documentation, and operational support
Evaluate how providers can assess, mitigate, and respond to risk through contractual obligations, internal risk assessment, auditing and monitoring, and payer alignment

This webinar is part of PYA’s Healthcare Regulatory Roundup, a popular series during which PYA experts provide practical insights on the latest industry regulatory developments. For more than 40 years, PYA has been committed to regulatory compliance and helping healthcare organizations create attainable compliance programs while mitigating risks.