If your clinic works with Medicare Advantage plans, or even just documentation and coding for patients enrolled in them, you’re about to be impacted by something big.
Risk Adjustment Data Validation (RADV) audits are no longer occasional events. They are now annual, wide-ranging, and expanding in scope faster than many clinics realize. The implications for FQHCs and RHCs are serious, especially in a year when announcements for Medicaid cuts and budget stress are already making it difficult to stay afloat.
This isn’t about panic. It’s about preparation.
We’ve been in the business of audit preparation and compliance for over 35 years. And we’ve never seen a shift like this. Here’s what you need to know now and what you can do about it.
What’s Happening with RADV Audits in 2025?
RADV audits are used by CMS to confirm the accuracy of diagnosis codes that Medicare Advantage (MA) plans submit for risk-adjusted payments. Historically, these audits targeted a limited sample of MA plans. In 2025, that changed.
CMS has now committed to:
- Auditing every Medicare Advantage plan contract annually
- Reviewing 200 records per contract year
- Completing a backlog of 2018–2024 audits by early 2026
- Applying extrapolated recoupments based on audit findings
This change is driven by growing concerns that diagnosis codes are being over-reported or unsupported. And while the target is the MA plan itself, documentation comes from your clinic.
If the documentation doesn’t support the diagnosis code submitted, especially if it supports HCC, the payer may pass clawbacks down to the providers. That means your clinic.
Why This Matters for FQHCs and RHCs
Community health centers often serve patients with complex conditions and multiple comorbidities. That should work in your favor for risk adjustment accuracy, but only if documentation is airtight.
Unfortunately, the reality that we see every day is:
- Problem lists are often outdated or overly cluttered
- Chronic conditions are under-documented or carried forward incorrectly
- ICD-10 codes are often selected to “match” history, not current documentation
- Many clinicians haven’t been trained on risk adjustment documentation expectations, let alone proper coding
- EHR templates are sometimes copied forward with errors or omissions
All of this creates exposure during a RADV audit. The auditor is not reviewing your intention; they are reviewing what was actually documented.
And that’s where clinics get hurt.
The Hidden Costs of Documentation Gaps
Here’s the risk:
If your clinician codes a condition, but the documentation doesn’t fully support management of that condition, that HCC may be disallowed. Multiply that by 10 charts. Then by 200 charts. Then extrapolate across a population of thousands.
For an MA plan, that can mean a six- or seven-figure recoupment. For clinics, the result can be:
- A freeze or clawback on shared savings payouts
- Sudden requests for bulk chart reviews
- Increased pressure from payers on documentation “corrective action plans”
- Lost contract renewals or VBC program participation
In short: even if you’re not the payer, you’re part of the documentation chain, and payers are tightening up on documentation requirements.
What Does RADV-Ready Documentation Look Like?
To protect your clinic, coding and documentation must work together.
Here’s what we recommend as a baseline for RADV readiness:
- Accurate Problem Lists
Problem lists should reflect current, active conditions; not every diagnosis the patient has ever had. Conditions like hypertension, diabetes, and CKD need to be carried forward only if they were assessed and documented as still being managed.
- HCC-Specific Documentation
Diagnoses that impact risk scores must show clear documentation using MEAT criteria. Example:
“Hypertension: BP 138/88 today, stable on current dose of lisinopril, will recheck in 6 weeks. “
That is RADV-ready. Simply stating “HTN” without assessment or plan? It won’t pass.
- Date Specificity and Linkage
Documentation must match the date of service for the HCC submission. Coders should never assume code assignment based on history alone.
- Avoid Copy-Paste Errors
Audit teams often catch duplicated documentation from previous notes with no updates or context. These create risk, not efficiency.
- Clinician Education
Clinicians are not coders, and they shouldn’t have to be. But they do need to understand how their notes impact compliance and risk-based reimbursement. Most don’t. And most haven’t been trained on RADV-readiness.
What You Can Do Right Now
RADV audits aren’t coming someday. They’re happening right now. So what’s actionable?
Conduct a Pre-Audit Assessment
Review E/M and ICD-10 documentation for a sample of patient charts across providers. Look specifically at chronic condition management, documentation language, and problem list accuracy.
Clean Up Your Problem Lists
Start with your most frequently seen conditions—diabetes, hypertension, CKD, depression, asthma—and work with providers to confirm or remove as needed.
Train Providers on Risk Adjustment
Give clinicians clear examples of what’s needed for HCC support. Short training, followed by case review, makes a big difference.
Audit Denials and Shared Savings Feedback
If payers are providing feedback on documentation gaps or shared savings disputes, track patterns now and build solutions around those gaps.
Consider External Support
If your team is already stretched thin or doesn’t have the bandwidth to take on audit prep, you don’t have to do it alone.
How BCA’s Fractional Support Services Can Help
Our Fractional Support Services were built to help clinics like yours prepare for audits, clean up documentation, and stay compliant, without adding full-time staff.
Our entry-level support package (starting at $3,500/month) includes:
- Two structured audits per provider per year
- One-on-one provider training tied to real chart findings
- Denial review and workflow coaching
- Credentialing and revalidation tracking
- Quarterly billing policy compliance reviews
- Monthly dashboard reporting to identify red flags early
Higher-tier packages also include:
- Custom training and new clinician onboarding
- AI scribe and coding implementation guidance
- Full A/R oversight and appeals support
- Quality metric documentation reviews and UDS reporting help
We don’t just identify the problem. We help you fix it and stay ahead of what’s coming.
We’re Here to Lighten the Load
We know this is a hard year. Clinics are under pressure to do more with less, while facing greater audit exposure than ever. You’re not alone. And you don’t have to figure it out by yourself.
If you’d like to talk through where your clinic stands, or what would make a difference, we’re here.
Schedule your free consultation
Book time with BCA
No sales pitch. No pressure. Just a conversation about how to protect your revenue and your mission in a tougher environment than we’ve ever seen before.