Rising Denials and Expanding RADV Pressure
Healthcare information management (HIM) leaders are confronting escalating payer denials and heightened risk adjustment data validation (RADV) scrutiny as CMS expands audit extrapolations back to payment year 2018 and prepares to fully implement the V28 risk adjustment model in 2026.
Although a recent federal court ruling temporarily vacated CMS’ 2023 RADV final rule, the agency’s appeal means increased audit activity may still lie ahead.
e4health Experts Weigh In on Audit Readiness and Denial Trends
Experts from e4health emphasize that HIM teams must remain audit-ready. Jeanie Heck, BBA, CCS, CPC, CRC, education consultant at e4health, notes that the court decision represents a significant but potentially temporary check on CMS’ enforcement efforts.
Meanwhile, Gina Stewart, MBA, BSN, RN, CCS, CCDS, vice president of coding quality and education, and Kim Felix, RHIA, CCS, director of education at e4health, highlight growing trends toward complex clinical validation denials—particularly for high-risk diagnoses such as sepsis, malnutrition, and respiratory failure.
Strengthening Documentation and Compliance to Protect Revenue
Together, these insights underscore the need for strong clinical documentation, rigorous validation of hierarchical condition categories, and proactive education strategies to reduce denials and strengthen compliance in an increasingly aggressive audit environment.
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