Medicare RADV Readiness

(return to MetaStar Readiness Series)

Proactive Audit Support for Medicare Advantage Plans

The Centers for Medicare & Medicaid Services (CMS) dramatically expanded its Risk Adjustment Data Validation (RADV) efforts, shifting from a selective audit model to a universal one. All eligible Medicare Advantage (MA) contracts are now subject to annual RADV audits, with CMS increasing sample sizes, deploying thousands of coders, and actively recouping overpayments.

MetaStar’s Medicare RADV Readiness service line is built to help MA plans stay ahead of this intensified oversight. Our readiness model identifies documentation gaps, validates diagnosis coding, and prepares internal teams to respond confidently before CMS initiates formal audit activity.

Medicare RADV Readiness – What MetaStar Offers

1. Pre-Audit Medical Record Review
   We conduct a structured review of diagnosis codes previously submitted to CMS that map to Hierarchical Condition Categories (HCCs), checking each for documentation support using Monitor, Evaluate, Assess/Address, Treat (MEAT) criteria. We flag unsupported, over-documented, or missing clinical indicators and provide actionable insights.
   Deliverable: HCC Validation Report with abstractor notes and MEAT compliance findings
2. CMS Audit Preparedness Consulting
   Our team walks clients through CMS RADV mechanics, timelines, documentation expectations, and internal readiness assessments. We help organizations identify risks and prepare documentation workflows that align with CMS guidance.
   Deliverable: CMS RADV Playbook plus Readiness Assessment Report
3. HCC Coding and Compliance Training
   We provide tailored education for clinical coders, documentation specialists, and compliance staff. Topics include RADV audit pitfalls, HCC abstraction best practices, and documentation improvement strategies.
   Deliverable: Customized Training Package plus RADV Readiness Checklist
4. Optional: Retrospective HCC Opportunity Review
   We identify risk-adjustable conditions not previously submitted but documented in the chart, offering insights that could support future Risk Adjustment Processing System (RAPS)/Encounter Data Processing System (EDPS) submissions if allowable.
   Deliverable: Missed Opportunity Report

Medicare RADV Readiness – What We Don’t Do

To maintain independence and comply with CMS program integrity expectations, MetaStar:

• Does not assist with active CMS RADV audit submissions.
• Does not compile or deliver medical records to CMS.
• Does not advise on audit response strategy during a live audit.

Our services are offered exclusively before CMS initiates a formal audit.

Why MetaStar?

• Trusted validation and abstraction partner for over 20 years
• Active IVA Entity under the HHS-RADV program
• Experienced in risk adjustment, coding validation, and compliance consulting
• Pre-audit only focus keeps our role neutral, independent, and CMS-aligned

Get Ahead of RADV

Let us help your organization prepare for CMS’s expanding audit requirements. Contact us to schedule a readiness consultation or request a tailored proposal.