Wynda Clayton, MHA, RHIT, CRC
Former CMS RADV Auditor · 20+ years in healthcare risk adjustment
Wynda Clayton, MHA, RHIT, CRC
Former CMS RADV Auditor · 20+ years in healthcare risk adjustment
The RADV Defensibility Pocket Guide for 2026
CMS confirmed on January 27, 2026 that PY 2020 RADV audits begin in February, with audits initiating every three months going forward. This pocket guide is a former CMS auditor’s field-ready framework for defending every HCC you submit.
What’s inside the pocket guide (checkmark list):
✓ Pre-audit readiness checklist: 8 items your team needs in place before a CMS notification arrives
✓ The “Court of Law” test: how to decide if a diagnosis is defensible or not
✓ Chart-level defensibility checklist: the 10 things a CMS auditor looks for in every chart
✓ Condition-specific documentation requirements for CKD, diabetes, CHF, and acute stroke
✓ Red flag patterns that trigger deeper CMS review (with a real $250K clawback case study)
“You can’t play the game by still using spreadsheets. If CMS is using AI, you need to match them. But whatever tools you use, you have to test them, make sure they’re accurate, because one mistake can cost you millions.”
Wynda Clayton, MHA, RHIT, CRC
Former CMS RADV Auditor · 20+ years in healthcare risk adjustment
Wynda Clayton, MHA, RHIT, CRC
Former CMS RADV Auditor · 20+ years in healthcare risk adjustment
20+
Years in healthcare
$17B
Estimated annual MA overpayments (CMS, Jan 2026)
5-8%
Overpayment rates found in PY 2011-2013 audits
5 mo
Medical record submission window (restored by CMS)
WHY MOST PLANS AREN’T READY
The gaps CMS auditors find every time
5-Month Submission Window, Variable Sample Sizes
CMS restored a 5-month medical record submission window but audits now initiate every 3 months. Sample sizes range from 35 to 200 enrollees based on contract size. Smaller contracts get smaller samples, but no one is exempt.
Spreadsheets Can't Manage Rolling Audits
With audits initiating quarterly, you could have overlapping audit cycles for PY 2020, 2021, and 2022 running simultaneously. Tracking enrollees across concurrent audits in Excel is a recipe for missed deadlines.
Only 2 Medical Records Per HCC
CMS confirmed the max of 2 medical records per audited HCC remains for PY 2020+. Only one valid record is needed to support payment, but you get just two shots to prove it. Every submission has to count.
CMS Is Bringing AI to the Audit Process
The January 2026 memo confirms CMS plans to use AI-powered tools to support medical coding reviews. Human coders still make final decisions, but AI is accelerating how fast CMS can process audits. Your tools need to match.
IF YOU NEED MORE THAN A POCKET GUIDE
How RAAPID manages the full RADV audit workflow
01
Ingest CMS Notification
Upload your CDAT file. Auto-generated chase lists, enrollee assignment, and deadline tracking from day one.
02
AI-Powered Chart Validation
Neuro-Symbolic AI reviews each chart, validates HCCs against MEAT criteria, flags unsupported codes with full evidence trails.
03
Expert Review + Submission
Certified auditors review AI findings, rank HCCs, and generate CMS-compliant response packages ready for submission.
WHY SWITCH
Your Current Process vs. RAAPID
| Capability | Manual / Spreadsheets | RAAPID |
|---|---|---|
| Chase List Generation | Hours per audit | Auto from CDAT |
| Chart Review | 40+ min per chart | Under 8 minutes |
| HCC Validation | Coder judgment only | AI + certified auditor |
| MEAT Evidence | Not captured | Auto for every HCC |
| Concurrent Audits | Separate files | Single dashboard |
| CMS Submission | Manual assembly | One-click export |
| Audit Trail | Emails / notes | Complete, timestamped |
FROM RISK ADJUSTMENT LEADERS
What health plans say
"I was hoping for 90% AI code suggestion match rate and RAAPID got 96%, which is excellent."
Director, Risk Adjustment Coding Operations
Health Plan, 200K+ Members
"Our coding team does not like change, but our coders and auditors love RAAPID. They feel like you are part of our coding team."
Sr. Director, Risk Adjustment
Regional MA Health Plan
Get prepared before CMS sends the letter
Download the pocket guide now. Talk to our audit team when you’re ready.