With the recent announcement that CMS plans to ramp up its Medicare Advantage Risk Adjustment Data Validation (RADV) audits by hiring hundreds of medical coders to determine whether medical records support risk adjustment diagnoses, many providers are left wondering: Will this affect me directly? 

The short answer is this: Possibly. 

Increased Medicare Advantage risk adjustment audits will likely result in more administrative work and financial risks for physicians, especially those with a large Medicare Advantage patient base. Following are 3 possible scenarios that could occur commensurate with CMS’ renewed focus on Medicare Advantage — and how physicians can prepare.

As CMS begins to increase Medicare Advantage risk adjustment audits to address an ongoing audit backlog, providers may start to notice an uptick in medical record requests. There may also be stricter expectations for clinical documentation of risk-adjusted diagnoses given the propensity for error that the OIG found. 

How to prepare: Talk with your staff now about who will gather, review, and submit records in response to Medicare Advantage risk adjustment audits and payer requests. Designate a point person to manage communication with Medicare Advantage plans and oversee physician risk adjustment in healthcare.

As CMS scrutinizes Medicare Advantage plans, those plans could, in turn, recoup payments from providers who submit codes that are not justified.

How to prepare: Apply the MEAT criteria when documenting. The acronym ‘‘MEAT” stands for monitor, evaluate, assess/address, and treat. Using this strategy ensures clinical documentation supports the assignment of all diagnoses, including those that contribute to risk-adjusted payments. 

In addition, provide ongoing training for coders, billers, and clinicians on: 

As Dr. Soma Mandal, MD, internal medicine specialist, explains, “As CMS ramps up Medicare Advantage risk adjustment audits, physicians face growing pressure to ensure documentation aligns with coding. Unsupported diagnoses can lead to payment recoupments, legal exposure, and increased administrative burden — especially for those with a large Medicare Advantage patient base.” 

Also, use EHR tools or analytics platforms to flag documentation gaps, coding mismatches, and high-risk areas.

If CMS Medicare Advantage risk adjustment audits uncover patterns of upcoding or unsupported diagnoses, physicians may face investigations for fraud or abuse, especially when there is a history of inflated risk scores. 

How to prepare: Conduct internal and/or external risk adjustment audits to ensure coding aligns with documentation and to monitor trends and areas for improvement. Be mindful of copy and paste documentation tools and other templates that encourage physicians to report risk-adjusted diagnosis codes that do not meet reporting criteria.

For example, physicians should not report past diagnoses that do not affect the patient’s care, treatment, or management at the time of the encounter. Reporting these diagnoses can artificially inflate the patient’s risk score.

Looking for more resources on physician risk adjustment in healthcare, and how to prepare for Medicare Advantage risk adjustment audits? Here’s a checklist we’ve created to help you succeed.  

In addition, here’s a RADV rulebook to help you understand the audit process and how it affects your medical practice.

Documentation and coding:

Compliance and legal preparedness:

Staff training:

Communication and follow-up:

Technology and tools:

According to Dr. Mandal, “Now more than ever, physician risk adjustment in healthcare must go beyond compliance; it’s about proactively using MEAT criteria, leveraging EHR tools, and training staff to ensure accurate, defensible coding. By tightening documentation workflows and conducting internal audits, providers can protect revenue and stay ahead of regulatory scrutiny.”

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