Every diagnosis a Medicare Advantage plan submits to the Centers for Medicare & Medicaid Services (CMS) starts in the exam room. A clinician sees a patient, makes a clinical assessment, and documents that finding. When an audit occurs later, they're really asking one thing about that moment: does the record accurately reflect what was submitted?
As a physician, I've perhaps approach the audit conversation a little differently than most. For health plans, a Risk Adjustment Data Validation (RADV) audit is certainly a compliance event; however, audit readiness comes down to how well the clinical documentation tells the clinical story, and that isn’t something you can assemble at the last minute. The point of the audit isn’t really to capture a sample at a moment in time, it’s to encourage accurate, effective documentation for all patients at all times.
CMS is expanding RADV audits, which changes the paradigm for Medicare Advantage organizations. When audits are rare, a last-minute scramble is painful but survivable. When they're the norm, the scramble never stops, and your coding, compliance, and clinical teams shouldn’t be caught unprepared. Worse, you tend to find problems after submission, when your options are limited.
This isn’t a hypothetical risk. The U.S. Department of Health and Human Services Office of Inspector General (OIG) continues to target diagnoses it considers at high risk of being unsupported by medical records. In one 2026 review, OIG found unsupported acute stroke diagnoses codes for every enrollee in its 97-person sample and estimated $462 million in potential net overpayments for 2021. That makes continuous readiness more than an audit exercise. It’s an opportunity to catch questionable diagnoses, documentation gaps, and coding issues before they become findings. As always, it’s better to do it right the first time to avoid finding preventable errors later.
Clinicians know this pattern all too well. If you only deal with a chronic condition when it lands a patient in the emergency room, costs rise and outcomes decline much more than you would see with steady monitoring. Prepping for audits in bursts is the ER model of compliance.
This is why Cotiviti has introduced Audit Risk Members (ARM), a new module in our Retrospective Review coding solution. ARM builds CMS audit logic right into coding review and scans a plan's member population proactively to flag the members and conditions most likely to carry audit risk. Instead of waiting to find out which charts an auditor cares about, a plan can see where its own exposure sits and begin there. Identifying risk proactively not only flags the opportunity to correct in the moment, but to identify trends and improve processes overall.
Here's something we don't say enough: accuracy cuts both ways. If a diagnosis isn't clinically supported, the right move is to delete it, not to cross your fingers and hope nobody looks. ARM's workflow tools let payers validate, update, or remove diagnoses in a structured, auditable way. A plan that can show consistent, traceable decisions across its coding review is in far better shape than one that can only show volume.
Whatever risk adjustment tools a plan uses, these are good ones to ask:
Audits are a fact of life for Medicare Advantage organizations. The good news is that you can help to get ahead of them by making accuracy a part of everyday coding, including the willingness to remove a diagnosis the record doesn't support. Start by finding out where your exposure sits today. That's a much better place to be than finding out from an auditor.