Overview
The Challenge
A Medicare Advantage plan with 150,000 members had historically taken a reactive approach to RADV compliance — addressing audit findings after they occurred rather than preventing them. Their most recent RADV audit resulted in a 12% error rate and $2.3M in payment recovery demands.
With CMS expanding RADV extrapolation to all MA contracts, the plan recognized that their reactive approach would become financially unsustainable.
- 12% error rate in most recent RADV audit — above the 5% safe harbor threshold
- $2.3M in payment recovery demands from unsupported diagnosis codes
- No systematic pre-submission validation process for HCC-supporting documentation
- Coding and compliance teams working in silos with no shared visibility into audit risk
The Solution
The plan implemented VBC Risk Analytics' RADV Scrubber platform for comprehensive pre-submission validation of all HCC-supporting diagnosis codes.
- Automated pre-submission scrubbing of 100% of HCC-supporting encounters before CMS submission
- Documentation sufficiency scoring that flags encounters where clinical records may not support submitted diagnoses
- Provider-specific audit risk dashboards identifying which providers and conditions carry the highest exposure
- Quarterly mock RADV audits using the same sampling methodology CMS employs
Three downloads risk adjustment teams actually use
Checklists, playbooks, and frameworks — built for analysts, auditors, and VPs working RAF, RADV, and HCC.
2026 RADV Audit Readiness Checklist
12-point compliance checklist for documentation, diagnosis code validation, extrapolation defense, and pre-audit scrub workflows.
RAF Score Optimization Playbook
Tactical guide for analysts: HCC recapture workflows, V28 transition impacts, prospective gap-closure plays, and KPIs that move RAF lift.
Risk Adjustment Analytics Playbook
How payer leaders sequence prospective and retrospective risk adjustment for compounding RAF lift. Deployment patterns, KPIs, and a VP-level operating rhythm.
Results
- 94% pre-submission catch rate — documentation issues identified and resolved before CMS submission
- 67% reduction in audit exposure — measured by error rate decline from 12% to under 4%
- Zero material findings in subsequent RADV audit — all sampled records had adequate supporting documentation
- $8.6M in protected revenue — extrapolation liability that would have applied at the previous error rate
- Provider documentation quality improved 35% — feedback loop from scrubbing results drove behavioral change
"We went from dreading RADV audits to welcoming them. The pre-submission scrubbing gives us confidence that every submitted HCC has the documentation to back it up."— Chief Compliance Officer, Medicare Advantage Plan