Your organization is using the same RADV audit defense strategy that worked successfully in 2023. Compile medical records. Organize documentation chronologically. Highlight MEAT criteria. Submit to CMS. Wait for results. That strategy is failing in 2026. Not because your documentation got worse. Because CMS’s audit methodology evolved and your defense strategy didn’t. Here’s what changed about RADV audits in 2026 and why your old playbook doesn’t work anymore.
The Cross-Year Pattern Analysis
In 2023 RADV audits, CMS reviewed sampled member-years in isolation. They looked at 2020 documentation, validated HCCs, moved to the next member-year. Each audit sample was independent. In 2026, CMS is analyzing patterns across multiple years for the same members. When they sample member A for payment year 2023, they also pull that member’s data from 2021, 2022, and 2024. They’re looking for consistency. Did member A have diabetes with nephropathy documented every year? Or does nephropathy appear in 2023 (the audited year) but not in surrounding years?
If your audited year shows significantly higher acuity than preceding or following years without clear clinical explanation, CMS questions whether 2023 documentation reflects genuine clinical status or one-year documentation enhancement. Your defense strategy needs to address temporal patterns. When submitting documentation for audited member-years, proactively explain any acuity changes compared to surrounding years. If RAF increased significantly, document the clinical events that caused it.
The System Design Investigation
In 2023 audits, CMS focused on whether individual diagnoses had adequate documentation. They validated MEAT criteria for each sampled HCC. In 2026, CMS is investigating the systems that generated the documentation. They’re requesting your risk adjustment policies, procedures, vendor contracts, CDI program materials, coder training documents, and provider communication templates.
They’re asking: Was your risk adjustment program designed to ensure accurate coding or maximize revenue? Do your systems have checks and balances, or are they optimized for one-way code addition?
Your defense strategy needs to demonstrate system integrity. You need to show that your risk adjustment program includes:
- Two-way coding practices (adding and removing diagnoses)
- Quality assurance focused on accuracy, not just capture
- Provider education emphasizing clinical documentation, not revenue
- Technology that flags potential overcoding, not just undercoding
- Metrics measuring compliance and quality, not just revenue
If you can’t demonstrate these elements, CMS interprets your audit findings more critically.
The Provider Pattern Scrutiny
In 2023 audits, if documentation was adequate, the HCC was validated. Provider patterns didn’t matter much. In 2026, CMS is analyzing provider-level patterns. They’re looking at which providers documented the audited diagnoses and how those providers’ documentation patterns compare to peers.
If Dr. Johnson documented 15 of your 30 sampled diabetic nephropathy cases, and Dr. Johnson’s diabetic nephropathy documentation rate is 300% higher than similar providers in your network, CMS questions whether Dr. Johnson is documenting more accurately or more aggressively.Your defense needs to address provider outliers proactively. If specific providers are overrepresented in your audit sample, explain why. Is it because they see sicker patients? Because they’re specialists? Because they have better documentation training?
If you can’t explain provider patterns, CMS assumes those providers are overcoding.
The Encounter Type Analysis
In 2023 audits, encounter type didn’t significantly impact validation. Documentation from wellness visits, urgent care, and specialist visits were treated similarly. In 2026, CMS is differentiating by encounter type. They’re more skeptical of diagnoses that only appear in wellness visits or retrospective chart reviews without corresponding documentation in problem-focused encounters. If a member’s diabetes with nephropathy only appears in annual wellness visit documentation but isn’t mentioned in quarterly endocrinology visits or urgent care for diabetic complications, CMS questions whether it’s real or documentation inflation during low-acuity encounters. Your defense needs to show diagnoses documented across multiple encounter types, not concentrated in specific settings designed to maximize capture.
The Retrospective Program Evidence
In 2023 audits, CMS validated documentation regardless of whether it came from original encounters or retrospective review. In 2026, CMS is scrutinizing documentation that originated from retrospective chart review programs. They’re requesting your retrospective program policies, asking which sampled HCCs were identified retrospectively, and questioning whether retrospective-identified diagnoses reflect real clinical status. If 60% of your audited HCCs came from retrospective identification and only 40% from encounter-based coding, CMS views your audit sample more skeptically.
Your defense needs to minimize reliance on retrospective-only diagnoses. Ideally, even retrospectively-identified diagnoses should have some encounter-based documentation during the year.
The Query Response Timing
In 2023 audits, if documentation was incomplete, you could query providers during the audit response period. Providers could add clarifying information. CMS generally accepted these addendums. In 2026, CMS is looking at query response timing more critically. If you query 50 providers during the audit response period and they all promptly add missing information, CMS questions whether that represents legitimate clarification or coached documentation enhancement. Particularly suspicious: providers adding identical or very similar language in response to audit-period queries. This suggests templated responses rather than independent clinical recollection. Your defense needs to rely primarily on documentation that existed before audit notice. Query-driven addendums should be minimal and clinically specific, not templated responses.
The Third-Party Documentation Reliance
In 2023 audits, documentation from specialists, hospitals, and other providers was generally accepted if it supported the diagnosis. In 2026, CMS is questioning heavy reliance on third-party documentation, particularly when your own providers’ documentation is vague or incomplete. If your primary care provider documents “diabetes” but the endocrinology consultant documents “diabetes with diabetic nephropathy,” CMS is asking: Did your PCP actually evaluate the nephropathy or are they just copying the specialist’s assessment? Your defense needs to show that diagnoses were evaluated by the coding provider, not just documented by someone else and copied forward.
What Actually Works
RADV audit defense in 2026 requires addressing systemic questions, not just validating individual diagnoses. Proactively explain temporal patterns showing why acuity changed across years. Demonstrate system integrity with two-way coding, quality focus, and balanced metrics. Address provider outliers with clinical explanations. Show diagnoses documented across multiple encounter types. Minimize retrospective-only diagnoses. Rely on pre-audit documentation rather than audit-period queries. Demonstrate that coded diagnoses were evaluated by the coding provider. The organizations successfully defending 2026 audits are the ones explaining context and demonstrating program integrity, not just submitting documentation and hoping for validation.