CMS expands RADV audits. Are you prepared?

Medicare Advantage plans: now is the time to overhaul your approach to compliance. The Centers for Medicare & Medicaid Services (CMS) recently announced updates to its approach to Medicare Advantage (MA) plan audits that could leave you scrambling to review multiple years' worth of data, fill documentation gaps, and respond quickly to auditor inquiries.  

It’s more important now than ever that MA plans stay audit-ready year-round. CMS has made reducing overpayments a top priority, and it’s implementing advanced technology to scale its audit efforts.  

MA plans must follow suit. Making compliance and audit readiness a priority while implementing technology backed by artificial intelligence (AI) in healthcare is an urgent imperative for plans that want to stay competitive in today’s environment.

What does CMS’s recent announcement to reduce overpayments do?

On May 21 CMS released this announcement informing MA plans of its new, aggressive approach to reducing Medicare overpayments. Medicare has been considered a “high-risk” government program by the Government Accountability Office. With overpayments estimated at $43 billion per year, even a small percentage of unsupported codes can result in millions in recoupments for a single plan.  

With so much pressure to reduce healthcare costs and, in particular, drive savings through a focus on fraud and abuse detection by the Office of the Inspector General (OIG), CMS is upping the ante on its risk adjustment data validation (RADV) audits. It’s introduced the following changes effective immediately:

• All MA plans will now have to undergo annual RADV audits. Previously, CMS selected 60 plans for RADV audits each year. These were usually higher-risk plans, plans that CMS believed would have a higher proportion of errors based on previous audit findings. Many health plans have gone years without a RADV audit.  

• More records will be reviewed per health plan. In the past, auditors requested 35 records for every audited health plan. Now, that number could be as high as 200.

• CMS is substantially increasing its audit infrastructure. In addition to implementing advanced technology to pinpoint unsupported diagnoses at an increased scale and accuracy, it plans to grow its team of medical coders by 50X this year.

• CMS will diligently work through its audit backlog from 2018-2024. It plans to complete all audits from that period by 2026. That means health plans could be subject to a higher volume of requests and, potentially, a higher volume of payment recoupment in a relatively short timeframe.

How does CMS’s recent announcement affect MA plans?

Perhaps the most far-reaching impact of CMS’s announcement is the annual requirement that all MA plans undergo the RADV audit process. Some MA plans have gone more than a decade without a RADV audit, and the last recovery of overpayments occurred following the 2007 audit payment year.

Even if your plan has undergone a recent audit and is familiar with the process, you will now have to submit additional records for review. The larger sample size means that you need an efficient and reliable way to easily request medical records and quickly validate them.

Finally, your plan must be prepared for multiple years’ worth of audits in a short time frame as well as possible payment recoupment for those years. MA plans with substantial documentation gaps and a high resulting number of unsupported diagnoses may be looking at significant recoupments with a serious financial impact.

What should MA plans prioritize today to stay ready for CMS annual audits?

Ready or not, CMS will be knocking on the door of every MA plan to conduct annual RADV audits. Instead of scrambling every year to extract the necessary records, respond to auditor inquiries, and risk financial losses and penalties, consider revamping your compliance program to stay audit-ready year-round. No plan is exempt. CMS is now auditing every MA plan, every year. The era of the “audit lottery” is over. Fortunately, proactive strategies and the right technology can help to keep your plan off of both the OIG and CMS’s radars.  

Prioritize provider engagement

At the top of every MA plan’s compliance to-do list should be working to engage providers in the task of year-round audit readiness. Offering ample opportunities for education around documentation can significantly reduce errors. Focus on the particular diagnosis codes CMS targets including:  

• Acute heart attack

• Breast cancer

• Acute stroke

• Colon cancer

• Embolism

• Lung cancer

• Major depressive disorder

• Prostate cancer

• Vascular claudication

Additionally, working with providers to offer clinical insights at the point of care, integrated into existing EHR workflows, can help close documentation gaps before they occur.

Accelerate record retrieval

Automating the medical record retrieval process does wonders for making audits as smooth and stress-free as possible. Automated retrieval cuts down on the time it takes to reach out to providers early in the reporting season. With the power of AI, your risk adjustment teams can even prioritize chases to improve turnaround times.

The exchange of records should also be secure, flexible, and seamless. Make sure you’re prioritizing automated digital retrieval through integration with EHRs, but also offer providers the option to use fax, email, or mail depending on their preferences.

Finally, make sure your retrieval technology integrates your data into a centralized view. When there are inconsistencies in the data, including potential data gaps or errors, you should be able to rely on your retrieval technology to flag them.  

Efficiently close documentation gaps in the review process

Finally, to stay audit-ready, it’s imperative to leverage both AI and clinical documentation integrity (CDI) specialists’ expertise to flag and close any documentation gaps before CMS does. Technology can help you identify unsupported diagnoses, combing through structured as well as unstructured clinical notes for validation. Then, CDI specialists can leverage their expertise to know when and how to query providers for additional context as well as work with them to close future documentation errors.  

How to choose the right RADV compliance technology partner

CMS is turning to advanced technology to power its new approach to audits, allowing it to search more broadly and deeply for unsupported diagnoses and overpayments. For your audit-readiness efforts, consider selecting a technology partner with these characteristics:

• Audit-ready by design. Your compliance technology partner should offer pre-claim RADV validation, post-visit review, and AI capabilities that link evidence for every single diagnosis.

• Real-time oversight. This is conducted via continuous audit logs and dynamic validation to help CDI specialists focus on audit-sensitive codes.

• Comprehensive data aggregation. Connections to 75+ EHRs and HIEs nationwide provide a complete, defensible record.

• Rapid adaptation. Advanced technology should update automatically to reflect new CMS requirements.

• Provider-centric workflows. You should be able to offer actionable, evidence-backed insights directly into your providers’ EHRs, reducing provider abrasion and ensuring compliance at the point of care.

Reveleer: Your committed partner in compliance

MA plans are entering a new paradigm of audit risk. This likely requires an overhaul of your existing compliance programs and a renewed commitment to accuracy, documentation, and evidence.  

Reveleer is committed to working with our health plan customers in this new environment to make staying compliant and audit-ready as simple and effective as possible, powering compliance programs with advanced, AI-powered technology and our over 15 years of expertise in the industry.  

Staying ahead of CMS’s new annual RADV audit requirements takes more than incremental change—it demands a full-scale compliance overhaul, powered by technology and workflows designed for year-round audit readiness.

This latest CMS announcement signals a renewed push to reduce overpayments and strengthen compliance oversight across all health plan types—not just Medicare Advantage. All payers should prepare now for heightened scrutiny and evolving expectations.

To help you stay compliant and confident, download our comprehensive IVA vendor checklist for ACA plans. It’s designed to ensure every line of business remains protected, audit-ready, and aligned with today’s intensified regulatory landscape.

‍