Audit360 RADV Shield™
Be audit-ready every day—reduce risk, protect revenue, and close documentation gaps.
Why RADV Matters
Medicare Advantage plans face increasing RADV audits from CMS, covering multiple plan years (PY2018–PY2024). Extrapolation exposure, tighter timelines, and stricter documentation requirements mean plans must ensure every HCC submission is accurate and fully supported.
Audit360 RADV Shield™ helps you:
Identify documentation gaps before an audit begins.
Reduce potential extrapolation exposure.
Accelerate audit responses with defensible, organized evidence.
Ensure end-to-end compliance from chart to submission.
Build confidence among internal auditors, providers, and CMS reviewers.
The Problem
Plans often struggle to keep pace with RADV requirements:
Charts may be incomplete, inconsistent, or missing documentation.
Chronic conditions are often under-documented, causing RAF loss.
Traditional audit prep is slow, fragmented, and error-prone.
Manual binder preparation increases the risk of missed deadlines and penalties.
Even small errors can lead to significant revenue loss and compliance risks. Plans need a streamlined, AI-assisted solution to reduce exposure and simplify preparation.
Introducing Audit360 RADV Shield™
Audit360 RADV Shield™ is an all-in-one RADV readiness and defense platform that unifies:
Retrospective chart validation
Prospective suspecting
Submission integrity checks
Audit binder automation
Powered by clinical-AI, it highlights gaps, prioritizes high-value tasks, and ensures you’re prepared for every audit scenario.
Why “Shield”? Because it helps you prevent, prepare, and protect—not just react to RADV audits.
Key Capabilities
1. Evidence-first Chart Validation
AI-assisted extraction of MEAT evidence from clinical notes.
ICD-10/HCC mapping with direct references to source notes.
Detect unsupported codes, missing documentation, or incomplete records.
Supports multiple document types: progress notes, discharge summaries, lab reports, and problem lists.
2. RADV Scenario Planning & Forecasting
Simulate audit outcomes under CMS sampling assumptions.
Forecast extrapolation exposure and potential recoupment risk.
Track high-priority HCCs and chronic condition gaps.
Provides actionable insights for internal compliance and remediation teams.
3. Submission Integrity & Traceability
Check EDPS/837 submissions for completeness and eligibility.
Full end-to-end lineage from diagnosis → HCC → RAF → submission.
Minimize risk of late or rejected claims.
Auto-highlight discrepancies between chart documentation and submitted codes.
4. Operational Workflows
Task queues for coders, auditors, and provider follow-ups.
Dual-control approval and audit trail tracking.
Auto-generated audit binders: member-level evidence, coding rationale, submission IDs.
Real-time status dashboards with deadline alerts.
5. Prospective Documentation Support
Provider-facing alerts and reminders for missing MEAT documentation.
High-impact chronic condition campaigns to improve RAF capture.
Preemptive gap closure before audit window ends.
Reduces scramble during audit season and improves plan-wide documentation quality.
New Features & Enhancements
AI-Powered Risk Scoring: identifies members with highest likelihood of unsupported HCCs.
Dynamic Binder Builder: customize binders for internal teams, auditors, or CMS submission.
Cross-Plan Analytics: compare documentation quality and RAF capture across multiple plan lines or TINs.
Integrated Reporting: export charts, dashboards, and binder summaries for leadership and regulatory review.
Training Insights: automatically highlight recurring provider documentation errors for targeted education.
What You Get
RADV Command Center: comprehensive dashboard for audit planning and exposure tracking.
Chart Evidence Explorer: side-by-side record viewer with highlighted MEAT evidence.
Binder Builder: auto-generate auditor-ready workpapers.
Submission Completeness Lens: last-mile validation to prevent avoidable gaps.
API/Flat-file Connectors: seamless integration with EDPS, 837, or EHR systems.
Real-time Alerts: for missing documentation, high-risk HCCs, and submission errors.
Benefits
Reduce unsupported diagnoses flagged in audits.
Lower extrapolation exposure through pre-audit remediation.
Improve HCC capture and RAF accuracy.
Faster audit response cycles (weeks → days).
Boost confidence across compliance, providers, and leadership.
Minimize manual effort and workflow friction.
Customer Success Examples
MA Plan Pilot: Identified >40% previously unsubmitted supported HCCs; actuarial-verified ROI.
Provider Group: Closed documentation gaps across 12 clinics, improving RAF by 8% in a quarter.
Consulting Firm: Reduced RADV binder prep from 2 weeks to 3 days with Audit360 automation.
Why Choose HDM
Clinical-AI with Receipts: every suggestion ties to actual evidence.
End-to-End Lineage: mirrors CMS RADV validation process.
Prospective + Retrospective Workflows: fewer hand-offs, less risk.
Flexible Deployment: for MA plans, providers, ACOs, and consulting partners.
Trusted Expertise: built on years of experience in RAF optimization and audit defense.
How It Works
Ingest & Normalize: claims, charts, problem lists, prior submissions.
Extract & Align: AI parses notes, normalizes ICD-10 codes, maps to HCCs.
Validate & Prioritize: support checks, gap analysis, risk scoring.
Remediate: route tasks to coders/providers with clear evidence and MEAT guidance.
Defend: assemble audit binders, simulate findings, monitor deadlines.
Compliance & Governance
HIPAA-compliant, SOC 2 / HITRUST-aligned.
Human-in-the-loop review and approvals.
Full audit trails for every action.
Role-based access and PHI minimization.
Who Should Use Audit360 RADV Shield™
Medicare Advantage Plans: reduce recoupments, respond faster.
Provider Groups & ACOs: close documentation gaps and protect shared savings.
Consulting/TPAs: deploy RADV Shield™ as a white-label solution, shorten audit prep cycles.
FAQs
Q: Does Audit360 support CMS-HCC v28 and earlier?
A: Yes, model versions and mappings are configurable.
Q: Can access be restricted to certain documents?
A: Yes, document-level redaction and scoped sharing ensure PHI safety.
Q: Can extrapolation risk be simulated?
A: Yes, scenario planning models sample outcomes and highlight potential exposure.
Q: Can providers correct documentation before audit windows?
A: Yes, prospective suspecting and provider campaigns are built in.