What types of plans are subject to RADV audits?

Medicare Advantage plans are specifically subject to Risk Adjustment Data Validation (RADV) audits because they rely on accurate risk adjustment data to determine appropriate payment levels from the Centers for Medicare & Medicaid Services (CMS). These plans are required to submit diagnosis codes for the beneficiaries they cover, and the accuracy of this data directly influences the funding they receive. RADV audits help ensure that the diagnosis data reported by these plans is valid and reflects the true health status of their enrollees.

Commercial health insurance plans, Medicaid managed care plans, and employer-sponsored health plans do not fall under the same regulatory framework established by CMS for Medicare Advantage plans, which is why they are not subject to RADV audits. The focus of RADV is primarily on ensuring the integrity of data within the Medicare program to maintain the efficiency and accuracy of risk adjustment in payment methodologies.