Las Vegas became the stage for a clear message at RISE West 2025: Medicare Advantage is entering an era of universal oversight. For risk adjustment leaders, the conference was not just about policy updates or technology showcases, it was a wake-up call. Oversight is accelerating, documentation standards are tightening, and the patient voice is reshaping priorities. At the same time, the path forward is clear: plans that build disciplined documentation integrity and real audit readiness will not only withstand scrutiny but also improve member experience.
Here are the key takeaways from the conference –
1. Oversight Is No Longer Selective
In May 2025, CMS announced plans to expand RADV audits from a limited sample to all 550 Medicare Advantage contracts. The agency outlined an increase in records reviewed per plan from 35 to as many as 200, along with the hiring of 2,000 coders by September 1, up from only 40 today. CMS estimated this expansion could recoup 479 million dollars each year beginning in 2025.
Speakers at RISE West reminded plans that while the industry is watching to see if CMS fully follows through, leaders should act as if universal audits are imminent. This shift creates a new baseline: every plan must assume it will be audited, and every diagnosis must be defensible.
For RA teams this turns oversight from a periodic project into a standard operating processes. Fragmented record pulls and ad hoc documentation reviews will no longer suffice. Building permanent surge capacity, mapping record sources in advance, and creating rapid clarification workflows with providers will be critical.
2. Scrutiny of Risk Adjustment Practices Is Intensifying
The policy discussion led by Georgetown’s Medicare Policy Initiative emphasized pending legislation such as the No UPCODE Act. This bipartisan bill would exclude health risk assessments and chart reviews from risk adjusted payments and require two years of diagnostic data, with the Congressional Budget Office projecting savings of 124 billion dollars over ten years if passed.
The OIG reinforced that scrutiny. Its analysis showed chart reviews added diagnosis codes 99 percent of the time, rarely removed errors, and often produced diagnoses with no associated claims or care within the twelve months of the coding event. OIG also flagged 7.5 billion dollars in questionable risk adjustment payments in 2023 tied to 1.7 million enrolee’s, many of which stemmed from in home assessments unsupported elsewhere in the record.
The message to RA leaders was unambiguous: every chart review must be anchored in provider documentation, and every in-home assessment must connect to real care delivery with follow up and ongoing care. Diagnoses unsupported by encounter evidence will not stand, and strategies that rely on administrative add-ons will come under direct challenge.
3. Documentation Integrity as the Currency of Compliance
A recurring theme across sessions was transparency. Regulators are not only focused on whether codes are accurate but also on the methods used to generate and defend them. AI was a central thread on Day 2. Lawmakers called for guardrails on AI use in prior authorization, while CMS itself plans to deploy new technology to scale RADV reviews.
For RA leaders, the implication is clear. Any use of technology in coding or audit support must be explainable and backed by human oversight. Plans will need audit trails that make sense to clinicians, regulators, and even members if challenged. Documentation integrity is therefore not only about accuracy but about credibility. Plans that can demonstrate fairness, human validation, and transparent processes will be trusted to navigate this new environment.
4. Special Populations Are Redefining Priorities
Day 1 gave the stage to patients who revealed how fragile documentation can be in populations with complex needs. Dual eligibles described fragmented experiences. Advocates stressed that without attention to housing, food, and mental health, physical health cannot be achieved. Others spoke of the stress of waiting on prior authorization decisions and the dangers of relying on automated denials.
Day 2 provided data to match those stories. OIG found that on average there are only five active behavioral health providers per one thousand enrollees, and many are not taking new patients. Those who are accepting patients often have long wait times. For RA, this means diagnoses in behavioral health and dual populations are the most at risk of being missed or poorly documented.
RA leaders must design workflows that account for these realities. Capturing behavioral health conditions requires tools that recognize access barriers. Documenting dual eligibles calls for collaboration with community resources that influence follow-up and care planning. In short, documentation must move closer to the lived experience of members if it is to be both accurate and equitable.
Annova’s Perspective from the Expo Floor
On the floor, one theme stood out: pre-audit document pulls remain a headache. Plans are still losing time and accuracy chasing down fragmented records across multiple systems. Vendors that promise efficiency but cannot trace diagnoses back to the original provider note risk creating more friction, not less. What resonated most were solutions that put providers at the center, offering nudges during the visit and simplifying how specificity is captured without extra steps.
The Path Forward
The shifts that surfaced at RISE West 2025 point to one reality. Risk adjustment leaders cannot treat audit readiness and member experience as competing priorities. The same workflows that deliver defensible documentation also reduce burden on providers and improve clarity for members.
At Annova, we are building exactly for that intersection. From tracing every HCC to its source note, to exporting audit ready packets in hours, to equipping providers with simple guides that fit naturally into visits, our focus is on making documentation both compliant and effortless.
The industry is entering an era where transparency, integrity, and member experience define success. Those who adapt now will not just survive heightened scrutiny, they will lead.
