CMS has released an
update on the status of Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audits, reaffirming that strengthening oversight and improving payment accuracy remain top priorities. With federal estimates indicating roughly $17 billion in annual MA overpayments due to unsupported diagnoses, CMS is moving quickly to address its backlog and accelerate audits across several payment years.
CMS expects Payment Year 2020 RADV audits to begin as early as February 2026, following its broader effort
announced in May 2025 to speed completion of audits for payment years 2018–2024. Recoveries tied to earlier audits (2011–2013) are also expected soon.
WHAT PROVIDERS SHOULD KNOW
In response to industry concerns about burden, timing, and transparency, CMS has made several refinements. These include:
- Longer time for plans to submit records, i.e. the five-month medical record submission window has been restored. This should result in fewer urgent chart requests and longer record request turnaround timeframes.
- More predictable audit timing – every three months – which should help to reduce overlapping requests. CMS is planning to publish a formal calendar to help organizations anticipate activity.
- Smaller, more tailored samples from 35-200 enrollees based on plan size. Smaller plans are unlikely to face the largest samples.
- Fewer document requirements reducing repetitive documentation demands. For each audited condition, plans may submit up to two medical records – but CMS only needs one valid record to support the diagnosis and thereby payment. However, providers should be aware that identifying the appropriate supporting record may still require reviewing multiple charts before locating the one or two that meet audit criteria.
- AI enabled coder support tools will be introduced to streamline reviews, though all overpayment decisions will remain with certified human coders.
CMS also acknowledged the September 2025 federal court ruling that vacated parts of the 2023 RADV Final Rule on procedural grounds. While CMS appealed the decision, it emphasized that RADV audits will continue moving forward.
To improve transparency, CMS will redesign its
RADV webpages to make it easier to locate the audit calendar, FAQs, and guidance. Plans and providers can also email
RADV@cms.hhs.gov with questions or issues.
WHAT PROVIDERS SHOULD DO
As SNF members receive documentation requests, you are encouraged to ask the requesting plan or partner to clarify whether it is related to a RADV audit or another plan‑initiated review if not clearly stated. Knowing the audit type helps ensure you can prioritize appropriately and manage workload.
AHCA will continue to monitor the implications for providers and share updates as CMS advances these audit activities.
Please contact
Nisha Hammel, Vice President, Reimbursement Policy & Population Health or
Rohini Achal, Population Health Policy Analyst, with questions.