Navigating RADV audits with confidence and the costs of unsupported diagnoses

CMS's removal of the fee-for-service adjuster has materially increased the financial exposure Medicare Advantage (MA) plans face when diagnosis codes cannot be supported. With the extrapolation methodology vacated by a federal district court in Texas and CMS's subsequent appeal filed in November 2025, health plans cannot wait for regulatory clarity before strengthening their audit posture.
‍

‍

In this Becker's Healthcare podcast, David DeHommel, Senior Vice President and General Manager of Payer Solutions at Reveleer, draws on fourteen years of direct risk adjustment accountability across Medicare Advantage, Medicaid, and ACA to explain what plans must build now. His perspective spans health plan leadership roles at Blue Cross Blue Shield of Michigan, Priority Health, Horizon Blue Cross Blue Shield of New Jersey, and Deloitte before joining Reveleer.

‍

‍

Featuring:

David DeHommel
SVP and GM of Payer Solutions
Reveleer

‍

‍

What you'll hear in this episode: 

• How the fee-for-service adjuster functioned as a statistical buffer between traditional Medicare data and RADV audit requirements, and why its removal increases unsupported-diagnosis exposure.
• Why CMS continues pursuing RADV payment-year audits for 2026 and 2027, regardless of how the extrapolation methodology is ultimately resolved.
• The shift from retrospective chart retrieval toward concurrent and prospective clinical intelligence programs, and what that shift looks like day to day inside a health plan.
• Why a centralized Clinical Data Repository (CDR) reduces provider abrasion and eliminates duplicate record requests across risk adjustment, quality, utilization management, and grievance and appeals.
• The 2027 encounter-linking requirement from CMS's advance notice, and its operational implications for retrospective chart retrieval and coding projects.
• A 90-day action plan for health plan leaders with gaps in their documentation infrastructure.

‍

Health plans have to focus and really execute in this area moving forward. It's a critical initiative and needs to be a part of their standard operating procedures."
_{- David DeHommel, Senior Vice President and General Manager, Payer Solutions, Reveleer}

‍

Three priorities for MA plans navigating RADV readiness

1. Build a Clinical Data Repository first: A centralized CDR is the fastest path to reducing provider abrasion and shortening retrieval cycles when an audit notification arrives. Most health plans store medical records in silos across departments, generating redundant requests from risk adjustment, quality, utilization management, and grievance and appeals. Consolidating that evidence base lets each department reuse what the plan has already retrieved, reducing provider burden and retrieval overhead at the same time.
2. Move chart activity upstream: Starting on 2027 dates of service, retrospective chart retrieval results must link to an encounter to count toward risk score calculation and reimbursement. Plans that shift concurrent activity into 2026 for 2026 dates of service close documentation gaps faster than those waiting until 2027 to complete the prior-year retrospective cycle. New members remain the only exception to the encounter-linking requirement.
3. Review provider contract language now: Agreements that escalate audit-related record requests above standard retrospective and concurrent requests reduce the time it takes to respond when CMS delivers a sample selection. Plans approaching contract renewals or addendum opportunities can add terms that prioritize federal audit requests specifically, building a faster response muscle into the relationship rather than relying on goodwill under deadline pressure.