Key Summary

• Strong documentation and clinical specificity are now essential as Medicare Risk Adjustment compliance thresholds have tightened.
• The CMS’s V28 HCC model transition demands clearer evidence, accurate coding, and continuous review to avoid major audit-driven recoupments.
• Enterprise accountability, technology support, and proactive audits strengthen the MRA compliance program.
• End-to-end, tech-powered RCM support can improve documentation quality with more than 98% accuracy and coding accuracy by up to 99%, increase MRA risk score by 40%, and boost audit readiness across all Medicare workflows.

Basic Medicare Risk Adjustment compliance is no longer sufficient. The CMS has intensified RADV audits, specifically targeting documentation gaps that lead to extrapolated overpayments, raising the stakes for every organization involved in Medicare Risk Adjustment. Now, the CMS has intensified RADV audits, specifically targeting documentation gaps that lead to extrapolated overpayments. This change has raised the stakes for every organization involved in Medicare Risk Adjustment.

The upgrade from V24 to V28 HCC models added 3,000+ diagnosis codes and distinguished risk score calculations. You now face higher documentation thresholds for conditions like diabetes with complications and chronic kidney disease.

Financial exposure has increased, too. Even a single failed RADV audit can trigger millions in recoupments across the entire book of business. These added pressures from regulatory bodies leave physicians, general practitioners, and group practices with no choice but to maintain precise, audit-ready documentation throughout the year. Stakes are high, and reactive approaches will no longer work.

This advanced guide provides six MRA strategies for building audit-resistant workflows and strengthening enterprise-wide accountability.

Strategy 1: Build a Compliance-First Documentation Culture

Start by making compliance the default, not a ‘pushed-to-the-last’ task. Your coding teams and clinicians need to have clear guidance on how to document chronic conditions with precise MEAT components, how to avoid unsupported diagnoses, and how both impact organizational sustainability.

Train providers on specificity requirements. For instance, ‘diabetes’ won’t capture the HCC, but ‘diabetes with diabetic chronic kidney disease’ will. Create real-time feedback loops that allow coders to flag documentation gaps before claims submission. In addition, develop specialty-specific templates that prompt providers to document severity, complications, and treatment plans.

When compliance becomes part of daily workflow rather than an annual training topic, your audit readiness improves exponentially. This is possible through technology, AI, and dedicated CDI and coding teams.

Strategy 2: Embed Compliance into Clinical Workflows

Prioritize breaking down the barrier between the treatment provided and coding accuracy. Instead of assigning CDI specialists to back offices, deploy their skills in clinical settings. They should review documentation during patient encounters, not days later.

Leverage the power of clinical decision support tools that prompt providers to document HCC-relevant conditions during hospitalization. Implement automated alert technology for incomplete diagnoses or missing links between conditions.

Ensure your nurse practitioners and physicians receive point-of-care guidance rather than post-visit corrections. When you integrate compliance tools into EHR workflows, documentation quality improves without adding an administrative burden.

Strategy 3: Establish Clear Accountability Across the Enterprise

It is critical to define who owns or is accountable for what in your MRA compliance program. For instance, your clinical leadership team should own documentation standards, coding teams must be responsible for accurate HCC capture and submission, and compliance officers should own audit response and risk mitigation.

Form service-level agreements between departments with measurable outcomes. Your risk adjustment committee should include clinicians, coders, compliance staff, and executive sponsors. Monthly scorecards should track documentation completion rates, HCC capture rates, and audit findings by provider and specialty.

Without clear ownership, compliance initiatives could crumble into cracks and diffuse responsibility, leaving no one truly accountable.

Meanwhile, partnering with a full-service RCM provider like HOM can help you strengthen accountability by bringing technology, structure, oversight, and operational clarity to every stage of Medicare Risk Adjustment workflows.

Strategy 4: De-Risk Your Third-Party Relationships

External vendors can expose you to compliance issues that you don’t see coming. If you work with retrospective review companies, third-party billing partners, or coding outsourcers, it is important to audit their processes rigorously to assess their ability to follow regulatory guidelines.

Ask for detailed documentation of their quality controls, error rates, and compliance training programs. Make sure they use certified coders who understand the nuances of the V28 model. Remember, your organization will remain responsible for submitted diagnoses regardless of who performed the coding. Therefore, establish robust contractual language that shifts financial liability back to the vendor in case of errors. It’s important to choose partners who demonstrate audit-ready processes, not just high HCC capture rates.

Strategy 5: Implement Smart, Technology-Driven Workflows

Technology plays a leading role in supporting advanced MRA strategies. This is because manual chart review doesn’t scale when you are managing thousands of members. On the other hand, NLP-powered tools help scan clinical notes for documented conditions missing from problem lists or diagnosis fields. Computer-assisted coding systems can suggest HCCs based on clinical evidence in the chart, and automated workflows can help you route flagged charts to appropriate reviewers based on patient complexity and reimbursement risk.

Technology handles pattern recognition and documentation mining while allowing your human experts to focus on clinical judgment, complex cases, and provider education. The combination creates both efficiency and accuracy.

Strategy 6: Build a Proactive Audit and Risk Monitoring System

Instead of waiting for the CMS to tell you where you are weak, build internal systems that help identify high-risk claims before submission. Use intuitive dashboards to analyze diagnosis patterns that typically activate RADV audits. These could be sudden spikes in high-value HCCs, conditions captured once and then forgotten, or diagnosed without enough clinical indicators.

Schedule quarterly internal audits using RADV methodology. Pull random samples stratified by provider, specialty, and HCC category, and review medical records against submitted diagnoses using CMS validation criteria. Flag charts that don't have face-to-face documentation, time-linked clinical evidence, or treatment notes.

When you see gaps, find the root cause. Is it provider documentation, coding interpretation, or workflow breakdown? Share the results with your RCM team and create targeted improvement plans. Predictive readiness combined with systematic internal auditing helps you fix issues while you stay in control of the narrative and stabilize RAF by reducing retroactive adjustments.

How HOM Supports Healthcare Organisations With Advanced MRA Compliance

Successfully implementing these advanced MRA strategies requires more than just knowledge. It demands the right operational partner. HOM combines specialized expertise with purpose-built technology to help healthcare organizations execute these compliance strategies effectively:

• Our tailored HCC/HHS Coding service ensures 99% accuracy in post-service diagnosis capture aligned with CMS and ACA guidelines.
• By efficiently integrating V28 updates into daily operations, our Clinical Documentation Improvement team works directly with providers to close documentation gaps using the proprietary AI-based tracking.
• Our EDPS/RAPS solution has helped process over 2 million cases with 96% accuracy. HOM uses real-time dashboards for data visualization and monitoring, risk adjustment score tracking, performance monitoring, and KPI tracking.

Having supported healthcare organizations across 15+ medical specialties for close to 8 years, our end-to-end, tailored RCM program can help you reduce revenue leakage by 90% and increase MRA risk score by up to 40%, while maintaining 98% accurate audit-ready documentation.

Ready to strengthen your Medicare Risk Adjustment compliance program? Request a free operational audit to identify your organization's specific risk areas and opportunities for improvement. Book a free audit now!

FAQs

1. What’s the most significant difference between V24 and V28 HCC models for compliance?

V28 requires stronger clinical evidence and specificity. This is because CMS removed many HCCs, shifted to ICD-10-aligned groupings, and also changed hierarchies. This means every diagnosis must show clear, defensible MEAT/TAMPER evidence.


2. What makes HOM’s HCC coding support different?

HOM uses experienced medical coders, AI-assisted tools, and strong quality checks to ensure each diagnosis reflects clear, supported documentation that aligns with CMS and state guidelines.


3. How often should we conduct internal RADV-style audits?

Quarterly audits provide the best balance between resource investment and risk mitigation. You may need more frequent reviews for high-risk populations or if any recent compliance issues. Annual audits don’t give you enough time to rectify systemic problems before CMS selects your data randomly for external review.


4. What Technology Investments Deliver the Best Compliance ROI?

AI-powered CDI tools that flag documentation gaps in real-time and integrated platforms that validate coding accuracy before claim submission show consistent returns.