During the RADV audit, which data is primarily validated?

The focus of the RADV audit is primarily on the validation of diagnosis codes submitted for risk adjustment. This is crucial because accurate diagnosis coding directly affects the risk adjustment process, which determines reimbursement rates for plans based on the health status of their members. Through the RADV audit, auditors meticulously verify that the diagnoses reported by health plans are substantiated by the medical records, which helps ensure that the coding is both accurate and in compliance with regulatory standards.

This emphasis on diagnosis codes is vital because it ensures that funds are appropriately allocated based on the actual health needs of beneficiaries. An accurate representation of a population’s health status is essential for fair and effective healthcare funding. The validation process helps organizations to avoid both overpayments for unsubstantiated claims, as well as underpayments that could hinder the provision of services for patients who require more support.

While the other data options, such as cost reports, patient satisfaction surveys, and provider performance metrics, are important in their respective contexts, they do not fall under the primary focus of RADV audits. The primary purpose of RADV audits is to verify the integrity of the diagnosis coding that informs the risk adjustment process, making the correct answer the diagnosis codes submitted for risk adjustment.