On May 21, 2025, CMS dropped a bombshell on Medicare Advantage plans:
RADV audits are no longer selective. They’re systemic.
For years, CMS audited about 30–60 plans annually. Now, they’re coming after all 550+ eligible Medicare Advantage contracts—every single year.
If you manage a Medicare Advantage plan, you’re officially on the list.
Why Now?
The short answer: $17 to $43 billion.
That’s how much CMS suspects MA plans are overpaid each year due to unsupported or inaccurate coding.
With the 2023 Final RADV Rule, CMS now has the green light to recoup those funds—retroactively to 2018. This isn’t about a few bad actors. It’s about setting a new national standard for risk capture and coding defensibility.
What This Means for MA Plans
This RADV overhaul isn’t just a compliance issue, it’s an enterprise-wide risk management problem.
- No More Rotations or Exemptions – Every plan. Every year. No exceptions.
- Higher Financial Exposure – 200 charts means more surface area for errors—and more exposure to extrapolated recoveries.
- Performance Scrutiny, Not Just Coding Checks – Plans will need to prove the clinical legitimacy of every HCC, not just hit coding benchmarks.
- Vendor & Provider Accountability – Plans must ensure that coding vendors, BPOs, EHRs, and downstream providers all meet documentation and audit-readiness standards.
- Provider Contracts Under the Microscope – Providers in value-based arrangements may face clawbacks if documentation gaps are tied to their coding.
The New RADV Reality
Let’s be clear: This isn’t just about fixing the past—it’s about transforming how plans operate going forward.
CMS is moving toward a model that is:
- Predictive – Using AI to anticipate errors
- Preventive – Expecting proactive compliance, not reactive defenses
- Relentless – Evaluating every plan, every year, systemically
What Should MA Plans Do Now?
1. Tighten Documentation Integrity – Train providers on specificity and medical necessity. Ensure documentation is complete, traceable, and audit-ready.
2. Run Internal RADV Stress Tests – Don’t guess your exposure—simulate it. Prioritize multi-year, high-risk HCCs in your reviews.
3. Partner with Audit-Savvy Vendors – Choose partners who do more than generate suspect HCC lists. Look for vendors who help with chart retrieval, coding validation, and defensible documentation—not just code chasing.
4. Build an Audit Defense Infrastructure – Have a team (internal or external) that knows how to handle CMS audit protocols and reconsiderations.
5. Prepare for a Culture Shift – MLR, actuarial, care management, provider relations—everyone is now part of RADV strategy.
Looking Ahead
CMS has made its position clear:
Optional compliance is over. Defensible coding is now mandatory.
Plans that prepare early—by aligning clinical teams, coding workflows, and audit strategies—will not only reduce risk but gain a competitive edge. This is about more than avoiding penalties—it’s about building a sustainable, compliant Medicare Advantage program in the long run.
Stay Tuned:
In our next post, we’ll break down:
How to Build a RADV-Ready Risk Adjustment Program Without Sacrificing Performance
(Yes, it’s possible to stay compliant and optimize revenue. We’ll show you how.)
FAQs
Q: When do these audits start?
They’ve already started for retrospective years. Full annual audits begin with 2025 plan year reviews.
Q: Does extrapolation apply to all audits?
Yes—for plan years 2018 and forward under the 2023 Final RADV Rule.
Q: What’s the best defense?
A: Clean documentation, proactive audits, coordinated provider training, and working with the right partners.
Q: How are providers affected?
A: Providers in value-based contracts may face clawbacks if documentation gaps are tied back to their coding.
Q: What’s CMS trying to achieve?
Greater payment integrity, less fraud, and a new national standard for risk adjustment accuracy.
Want to talk about how to get audit-ready?
Let’s connect.
