RADV Audits: What Medicare Advantage Plans Need to Know

Risk Adjustment Data Validation (RADV) audits are now an annual reality for every Medicare Advantage (MA) contract. In what’s widely seen as the most significant shift in risk adjustment oversight in more than a decade, CMS is moving quickly to clear a seven-year audit backlog and begin auditing all eligible contracts for each payment year.

This means more records, more scrutiny, and higher stakes for Medicare Advantage plans. For MA leaders, this shift isn’t just about compliance, it’s about protecting revenue, operations, and reputation in a much more aggressive audit environment.

In this blog, we break down what’s changing, what this really means for Medicare Advantage plans, and how to prepare now as RADV audits begin.

RADV Audits: What’s Changing

CMS’s updated RADV audit strategy introduces several major shifts that will impact every Medicare Advantage plan:

• All eligible MA contracts will be audited annually: RADV audits are no longer limited to a select group. CMS is standardizing audits across the entire Medicare Advantage program moving forward.
• Seven years of audits (PY 2018–2024) to be completed by 2026: The timeline is aggressive, and plans will need to respond quickly to record requests and audit demands.
• RADV audit sample sizes are increasing: Larger sample sizes of up to 200 records per plan per year means increased exposure risk, especially with extrapolation applied.
• CMS is ramping up their coding team from 40 to 2,000 coders immediately: This scale-up allows CMS to complete a massive volume of audits in a short timeframe.
• Technology and automation will be used to flag unsupported diagnoses: CMS is integrating tech into its RADV audit process, similar to how plans use it for targeting and abstraction.
• Extrapolation will now be applied more broadly: Even a small HCC error rate can lead to significant overpayment findings when extrapolated across the full member population.

How RADV Changes Impact Medicare Advantage Plans

The operational and financial implications of this RADV audit expansion are substantial. Plan leaders must shift from reactive compliance to proactive risk mitigation:

• Extrapolated overpayments could reach into the millions: With larger record samples and an average error rate of 5–8%, plans risk significant financial recovery actions from CMS.
• RADV audits will bring sustained financial and operational pressure: Plans must manage increased medical record requests, coding validations, and audit demands on top of day-to-day risk adjustment work. Retrieving older records will be especially challenging, with many falling outside the 3-year digital retrieval window.
• Documentation readiness is critical to RADV audit performance: Clinical documentation must be airtight and defensible, with complete and accurate coding that aligns with CMS guidelines. Plans should ensure claims-matched charts reflect complete code capture to support ongoing audit readiness.
• Timelines are accelerating and putting pressure on providers and plans: CMS aims to complete seven years of audits by early 2026, requiring a surge in medical record requests. Plans must be prepared to engage and incentivize providers for quick responses.
• Vendor partnerships will be critical: Plans will need experienced partners who can scale record retrieval, support high-accuracy coding, and manage audit response workflows.
• Reputational risk is real: Public audit findings or CMS enforcement actions can damage a plan’s standing with providers, regulators, and members.

How MA Plans Can Prepare for RADV Audits Now

Given the speed and scope of CMS’s audit expansion, readiness must be built into your core risk adjustment operations. Here’s how health plan leaders can prepare:

• Assess your readiness: Review your current processes for documentation review, coding validation, and audit response. Internal workflows must be built for audit speed, accuracy, and sustained volume.
• Partner strategically: Work with vendors who have proven, year-round, RADV audit experience and can support retrieval, abstraction, and coding at scale.
• Monitor extrapolation risk: Analyze your documentation and coding trends to understand where unsupported diagnoses may exist and how they could impact overpayment findings when extrapolated.
• Educate providers: Improve documentation practices at the source by offering training, clear expectations, and support—especially for older dates of service where record quality and availability may be a challenge.
• Stay current: RADV expansion is one part of a broader push for oversight and transparency in Medicare Advantage. Plans must stay proactive and future-ready as audit and compliance expectations evolve.

How Advantmed Supports Medicare Advantage Plans

At Advantmed, we’ve spent over two decades partnering with health plans to strengthen risk adjustment and reduce audit exposure. As RADV audits become a permanent part of Medicare Advantage oversight, we focus on supporting year-round readiness with accurate, scalable solutions. Our approach combines trusted provider relationships, industry-leading coding accuracy, and a complete code capture approach to help plans improve documentation, respond confidently to audits, and reduce extrapolation risk.

Conclusion

The RADV audit expansion represents one of the most significant shifts in Medicare Advantage oversight in the last decade. With annual audits, expanded record samples, and extrapolated overpayment risk now a certainty, plans face new financial, operational, and reputational challenges. Success will depend on year-round readiness: airtight documentation, provider engagement, scalable audit response, and trusted partnerships. Taking a proactive approach now can help your team stay ahead of compliance pressure and reduce audit risk as RADV oversight continues to expand.

Advantmed’s risk adjustment solutions support health plans with medical record retrieval, coding, and claims data validation. Learn more about how we can support your team.