Medicare Advantage Risk Adjustment Data Validation Program

Medicare Advantage Risk Adjustment Data Validation Program

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About the Program

Protecting our programs' sustainability for future generations by serving as a responsible steward of public funds is a CMS Strategic pillar. The Medicare Advantage Risk Adjustment Data Validation (RADV) program is CMS' primary way to address improper overpayments to Medicare Advantage Organizations (MAOs). During a RADV audit, CMS confirms that any diagnoses submitted by an MAO for risk adjustment are supported in the enrollee's medical record.

RADV audits occur after the final risk adjustment data submission deadline for the MA contract year and after CMS recalculates the risk factors for affected individuals to determine if payment adjustments are necessary. 

Risk adjustment discrepancies are identified when an enrollee's HCCs used for payment, which are based on MAO self-reported data, differ from the HCCs assigned based on the medical record review performed by CMS through the RADV audit process. Risk adjustment discrepancies can be aggregated to determine an overall level of payment error.

Questions about the RADV program should be sent to:

Page Last Modified:
12/15/2023 06:54 AM