On May 21, 2025, CMS didn’t just change the rules—they rewrote the playbook. Every Medicare Advantage plan, every year, will now face Risk Adjustment Data Validation (RADV) audits.
The instinct for some plans?
Pull back. Delete codes. Go conservative.
That’s not a strategy. That’s surrender.
In this new world, fear costs money. Readiness and defensibility protect it. Here’s how to move from panic to performance.
The New RADV Landscape
- All 550+ MA Contracts Audited Annually – No exemptions. No rotations. No hiding.
- Bigger Samples – Up to 200 charts per plan (vs. ~35 before). More charts = more exposure.
- 2,000 CMS Coders – A 5,000% staffing increase to speed reviews.
- AI-Driven Chart Flagging – Pattern recognition tools pre-spot suspect diagnoses.
- Full Extrapolation – One bad chart can snowball into millions in clawbacks.
- Backlog Clearance – 2018–2024 audits closed by early 2026.
This isn’t a one-year clampdown, it’s the new normal.
Why Fear Fails
Across the industry, we hear it:
“We’ve always been conservative.”
“Better to delete borderline codes.”
“We don’t want to attract attention.”
That thinking is a fast track to lost revenue and operational chaos. Why?
- Every Plan Is Audited – Past behavior doesn’t shield you.
- Over-Deletion Burns Revenue-Negatively impact you MLR – Many HCCs are fully defensible. Deleting them is like mailing CMS a check.
- Delay Costs You Options – Once CMS issues findings, your room to fix or appeal drops sharply.
- Fear Breaks Revenue Generation Processes – Inconsistent rules lead to confusion, undercoding, and missed legitimate revenue.
What Readiness Looks Like
At Annova, we see four pillars that separate the prepared from the exposed:
1. Proactive Record Validation
- Run mock RADV audits that mirror CMS’s process.
- Pull 200-chart samples, including chronic and high-risk HCCs.
- Verify every diagnosis is present, specific, and supported.
2. Precision-Driven Documentation
- Train coders and clinicians on CMS audit protocols.
- Close gaps on specificity and medical necessity.
- Make every chart “audit ready” before submission.
3. Data-Driven Risk Profiling
- Flag high-risk providers and facilities.
- Track HCC frequency shifts and clustering.
- Reinforce documentation before auditors target it.
4. Cross-Functional Alignment
- Finance – Quantifies the revenue at stake.
- Actuarial – Measures RAF score impact.
- Provider Relations – Educates and engages clinicians.
- Compliance – Ensures everything stands up under audit.
The Cost of Doing Nothing
Hoping for the best? Let’s do the math:
- One extrapolated finding above CMS’s error threshold can mean tens of millions in repayments.
- Deleting legitimate codes drops your RAF scores—and your annual revenue.
- Last-minute scrambles cost more than proactive prep.
Even in these early audits, one pattern is clear: proactive prep beats reactive fixes—every time.
Where Annova Fits In
- Mock Audits – chart reviews that flag and fix unsupported HCCs.
- Pre- & Post-Encounter Documentation – Capture compliant diagnoses before visits; validate before claims.
- Risk Profiling – Spot patterns that attract CMS attention.
- Education – Train teams to make defensible coding part of daily workflow.
Your Move
CMS has made it clear:
Every plan. Every year. Every diagnosis.
Plans that act now will protect revenue, defend compliance, and stay competitive. Those that wait will pay for it—literally.
If you’re debating code deletions, unsure of your documentation strength, or worried about extrapolation risk, now is the time to talk.
Annova can help you keep what you’ve earned—and prove you’ve earned it.
Schedule Your RADV Readiness Consultation
FAQs
Q: When do these audits start?
They’re already underway for 2018–2024. Full annual audits start with the 2025 payment year.
Q: Will extrapolation apply to past years?
Yes—retroactively to 2018 under the Final Rule.
Q: How many charts will CMS review?
35–200 per contract, based on plan size.
Q: Best way to prepare?
Proactive audits, airtight documentation, pattern analytics, and stakeholder education.
Q: Are small plans at less risk?
No. All plans are audited; smaller ones often have fewer resources
