In a significant move announced on May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) revealed plans to initiate annual Risk Adjustment Data Validation (RADV) audits for all Medicare Advantage (MA) plans. In this memo, CMS Administrator, Dr. Mehmet Oz, is quoted as saying “We are committed to crushing fraud, waste and abuse across all federal healthcare programs” and goes on to say, “While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.” This initiative will also address the backlog of audits from 2018 to 2024, with a targeted completion by early 2026. The RADV audits are designed to verify risk adjustment data, ensuring that the diagnoses submitted by MA plans for risk adjustment payments are supported by medical records.
Leveraging advanced technology, CMS will expand its audit coverage from about 60 MA plans annually to encompass all eligible MA plans—approximately 550 plans each year. Furthermore, the number of records audited per health plan will increase substantially, ranging from 35 to as many as 200 records annually based on the size of the plan. Although much remains to be seen about the roll-out timing of these new regulations, Medicare Advantage plans should be preparing for their implementation now. To help organizations prepare for these changes, we will cover the following topics:
1. The significance of expanding RADV audits
CMS’s announcement represents a bold step in enforcing RADV recoveries, a decision that could bring considerable financial consequences for MA plans. Facing payments ranging from thousands of dollars up to $600,000 or more for each unsubstantiated Hierarchical Condition Category (HCC) (under certain scenarios for a moderately-sized health plan) MA plans are now under pressure to ensure their submitted diagnoses are backed by medical record documentation.
This move represents a significant shift towards stricter oversight and accountability within the Medicare Advantage landscape. MA organizations must prepare for more rigorous RADV audits, which may necessitate revamping their internal processes to meet CMS’s elevated standards. This could mean investing in advanced data management systems, enhancing staff training, and implementing tighter compliance protocols to guarantee that all diagnoses are thoroughly documented and validated.
The impact of CMS’s approach will be closely watched by stakeholders across the healthcare sector, from providers to financial analysts, as they assess how these changes will affect the operational and financial dynamics of MA plans.
The newly reestablished urgency on MA RADV presents a challenge for MA organizations to adapt swiftly and effectively, ensuring compliance and minimizing financial risks. These developments mark a pivotal moment in the industry, as all eyes turn to see how MA plans will navigate this new landscape and what it means for the future of healthcare accountability.
2. Maximizing efficiency in MA risk adjustment documentation
To address the backlog of audits, CMS plans to implement advanced systems to improve the review of medical records and efficiently pinpoint diagnoses that might be questionable or unsupported. This technological upgrade aims to streamline the audit process, enhancing accuracy and accountability in validating risk adjustment data submitted by MA plans.
Given the CMS goal of completing all the backlog of PY 2018 – PY 2024 by early 2026, plans should prepare for the increased workload. While exact details of the upcoming RADVs and the advanced systems that would support this work are not yet known, our experience tells us that the workload for a single PY RADV is approximately as follows:
- Sample sizes: Sample sizes are 35 to 200 members based on health plan size.
- HCCs requiring substantiation: Approximately 200 to 650 HCCs will need to be validated.
- Medical records to collect: Around 2,000 medical records will need to be collected and reviewed.
- Locations to contact: You will need to reach out to approximately 300 to 400 healthcare facilities for record requests.
- Attestations: Collection of between 150 to 600 medical attestations to correct any medical record signature issues.
- Provider office calls: Anticipate making 2,000 to 3,000 calls to provider offices for record collection, follow up and attestation collection.
Note, the number of locations depends on how centralized the provider network is for each plan, so it will vary. However, it should increase in a roughly linear way as more members are added to a plan audit. Attestation needs can change year to year, but generally, older records and longer inpatient hospital records require more attestations.
As a result, effective collection of all risk-adjustable records is crucial for MA plans, even in instances where an HCC related ICD-10s did not appear on the initial claim. Collecting such records through an end-to-end risk adjustment solution can offer vital support to organizations with limited resources, particularly when other primary documentation is incomplete or unavailable.
The first step for conducting RADV audits effectively is a claim analysis to identify all risk-adjustable visits and determine which provider locations will be included in outreach efforts. This analysis will also establish a minimum set of records that should be expected from each provider as well as the HCCs that should be represented in each record.
To ensure the accuracy and completeness of submissions, it is advisable to pre-screen and review records thoroughly. This step is especially important for long inpatient stays where multiple physicians may have been involved. Addressing any missing information upfront can prevent potential issues down the line.
Moreover, obtaining attestations for potential signature discrepancies is essential to avoid losing credit for HCCs. It’s also important to ensure that your systems are equipped to handle years with split HCC models effectively. In cases where hardship requests are necessary, submit them early with comprehensive details, as these are typically approved only in extreme situations.
Lastly, establishing a robust system for quickly analyzing RADV feedback from CMS is crucial. This will enable you to home in on discrepancies and make informed decisions about which items to prioritize. By focusing on these areas, Medicare Advantage plans can enhance their risk adjustment processes and ensure more accurate and efficient fund allocation.
3. Understanding key deadlines for submission for payment years (2018 – 2024)
CMS is accelerating RADV audit activities for Payment Years (PYs) 2018 through 2024. As a result, MA plans must act quickly to meet deadlines for submitting corrections to risk adjustment data—particularly closed period deletions.
For this reason, CMS has issued formal notifications to various health plans, detailing revised deadlines for processing deletions related to ICD-10 and HCC codes. Meeting these updated deadlines is essential to ensure all necessary corrections are made before CMS begins selecting samples for review or analysis.
Table 1
The deadlines for submitting all closed period deletes for these samples are listed in the table below1:
| Payment Year | Relevant CMS System | Dates of Service | RA Data Submission for RADV Sampling deadline |
|---|---|---|---|
| 2020 | RAPS/ EDPS | Jan 1, 2019 – Dec 31, 2019 | June 16, 2025 |
| 2021 | RAPS/ EDPS | Jan 1, 2020 – Dec 31, 2020 | June 23, 2025 |
| 2022 | EDPS | Jan 1, 2021 – Dec 31, 2021 | June 30, 2025 |
| 2023 | EDPS | Jan 1, 2022 – Dec 31, 2022 | July 8, 2025 |
| 2024 | EDPS | Jan 1, 2023 – Dec 31, 2023 | July 15, 2025 |
4. How Milliman MedInsight can support your organization
The Milliman MedInsight® Risk Adjustment Platform offers a comprehensive suite of tools and services designed to optimize the risk adjustment process for healthcare organizations. Key benefits include enhanced data accuracy and integrity, enabling organizations to effectively identify and manage high-risk patient populations using proven benchmarks and on-demand clinical support.
Supported by a team of seasoned RADV specialists with expertise in managing MA audits since 2011 and Affordable Care Act (ACA) audits since 2014, our platform is purpose-built to fulfill RADV requirements, guaranteeing smooth and efficient audit processes. In addition, our full-time, on-shore, Registered Nurse-certified coders excel at finding the strongest support for your HCCs, while our administrative staff, with years of experience, ensures all details are handled correctly. We have developed effective strategies to collect even the most challenging records, knowing that every record is crucial for your audit success. If you need assistance navigating the RADV audit process, ensuring compliance, and optimizing your outcomes, the Milliman MedInsight team is here to help.
5. Where to find additional resources
Schedule a call: Connect with one of our healthcare analytics experts.
Visit our website: Learn more about our Risk Adjustment Platform offering.
Watch the webinar: Explore how the right risk adjustment solutions can optimize risk adjustment, RADV audits, and HEDIS gap closure.
References
1. Deadlines for the Submission of Risk Adjustment Data for Risk Adjustment Data Validation Sampling
