Risk adjustment is facing intensified regulatory scrutiny with the combined impact of recent updates from CMS, planned RADV audit expansion, and OIG and DOJ enforcement priorities. With greater exposure to potential liabilities, risk adjustment programs demand stronger controls, improved documentation integrity, and more proactive compliance strategies. Plans and providers must ensure every diagnosis is clinically justified, thoroughly documented, and clearly tied to the patient encounter, setting a higher standard for compliance and audit defensibility.
Risk adjustment is facing intensified regulatory scrutiny with the combined impact of recent updates from CMS, planned RADV audit expansion, and OIG and DOJ enforcement priorities. With greater exposure to potential liabilities, risk adjustment programs demand stronger controls, improved documentation integrity, and more proactive compliance strategies. Plans and providers must ensure every diagnosis is clinically justified, thoroughly documented, and clearly tied to the patient encounter, setting a higher standard for compliance and audit defensibility.
