To protect Medicare Advantage payments, CMS turned to a trusted team of coders and clinicians to get the details right.
The Challenge
The Medicare Advantage program pays health plans based on the health status of its enrollees, using a risk-adjusted model to calculate appropriate reimbursements. But that system is only as accurate as the diagnosis data it’s built on. Inaccuracies can lead to overpayments, underpayments, or missed indicators of fraud, waste and abuse.
To protect the integrity of the program and ensure that payments truly reflect patient health status, CMS launched the Risk Adjustment Data Validation (RADV) program. The goal? Review medical records and validate diagnosis coding across hundreds of Medicare Advantage contracts to detect and correct payment errors. It required a contractor with clinical and coding expertise, scalable operations, and airtight quality controls to review more than 100,000 medical records annually – quickly, accurately and securely.
Our Solution
As the RADV Medical Record Review Contractor (MRRC), RELI Group supported this massive, multi-year effort for CMS’s Center for Program Integrity. Our team included 39 full-time professionals – certified coders, physician reviewers, senior analysts, and operational SMEs – all trained in CMS-HCC models and RADV protocol.
We built customized QA frameworks, implemented inter-rater reliability monitoring, and tracked every finding and escalation. Our coders and reviewers documented lessons learned to feed continuous improvement – ensuring every RADV audit was more efficient than the last.
When foreign language records were received (especially from Puerto Rico), multilingual coders and physician reviewers ensured accurate abstraction and consistent application of CMS policies.
Real Impact
Over the life of the contract, RELI reviewed hundreds of thousands of records to validate the accuracy of risk-adjusted payments across the Medicare Advantage landscape. Our efforts helped CMS recoup improper payments; target fraud, waste and abuse patterns; and refine training and guidance for Medicare Advantage Organizations for better data submission practices.
RADV audits aren’t just an accounting exercise – they’re a cornerstone of payment integrity in one of the government’s largest healthcare programs. And with RELI’s expertise, CMS was able to uphold that integrity at scale, ensuring that every diagnosis counted.
