CMS expands RADV audits. Are you prepared?

Medicare Advantage plans: now is the time to overhaul your approach to compliance. CMS’s 2023 RADV Final Rule and its newer, more aggressive enforcement strategy have fundamentally changed how MA plan audits work, shifting from simple error correction to extrapolated financial risk that can apply across an entire contract.​ Under the Final Rule, CMS estimates extrapolated recoveries could reach roughly 4.7B dollars over time, making even modest error rates financially material for plans.

It’s more important now than ever that MA plans stay audit-ready year-round. CMS has made reducing overpayments a top priority. To achieve this, it is eliminating the “buffer” of the FFS Adjuster and is scaling its use of advanced technology and expanded coding resources to accelerate and deepen audits. Without the FFS Adjuster, every unsupported HCC is treated as a 100% overpayment, with no built‑in tolerance for normal documentation variance. Although the 2023 RADV Final Rule is subject to litigation and a court decision vacating it, CMS’s operational strategy remains focused on expanded RADV oversight, 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.

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

CMS’s updated RADV approach may now apply extrapolation starting with PY 2018 and is expanding audits from a small subset of contracts to all 550+ eligible MA contracts annually. With overpayments historically estimated in the tens of billions of dollars per year, even a small percentage of unsupported codes can result in multimillion dollar recoupments for a single plan.

To further reduce healthcare costs and address fraud, waste, and abuse, often spotlighted by the Office of Inspector General (OIG), CMS is upping the ante on RADV audits with several key changes:

• All MA plans should now expect ongoing, recurring RADV audits, not just a one-time event or “audit lottery.”

• More records will be reviewed per health plan, and extrapolation allows CMS to apply sample error rates across the entire contract, increasing financial exposure.
• CMS is substantially increasing its audit infrastructure, scaling its coding workforce from dozens to as many as 2,000 reviewers and leveraging advanced technology to pinpoint unsupported diagnoses at greater speed and scale.
• Compressed timelines, often 12–20 weeks to submit records, leave less room for manual retrieval or fragmented internal processes.

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_{*Subject to litigation and CMS discretion
Source: CMS, Update on the Status of MA RADV Audits (Jan 27, 2026).
Source: CMS, CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits (May 21, 2025).}

How does CMS’s recent announcement affect MA plans?

The most far‑reaching impact of CMS’s new RADV framework is the combination of annual exposure for every MA plan and extrapolated financial risk. A relatively small sample of unsupported HCCs can now be projected across an entire contract, creating significant clawback exposure even for plans that have not been audited in many years.

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.

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

CMS’s new RADV environment is pushing plans to prioritize revenue integrity to ensure every dollar is defensible under M.E.A.T. criteria and can withstand extrapolated audit scrutiny. Leading organizations are reframing their programs around defensible coding, not just revenue maximization, so every dollar can stand up to RADV review and extrapolation.

Ready or not, CMS intends to knock 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.

The era of the “audit lottery” is over. Fortunately, proactive strategies and the right technology can help to keep your plan off both the OIG and CMS’s radars.

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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

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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.

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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.

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Efficiently close documentation gaps in the review process

Leading payers are also adopting two‑way coding workflows that proactively delete unsupported diagnoses before submission, treating strategic deletions as low‑cost protection against extrapolated penalties.

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

As CMS operationalizes the 2023 RADV Final Rule with broader, extrapolated audits and AI‑enabled targeting, plans should strongly consider technology partners that can deliver audit‑ready data, negative‑coding workflows, and real‑time visibility into high‑risk HCCs. 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.

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Reveleer is 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 the essential strategies for year-round MA RADV audit readiness guide for MA plans and learn more about our RADV Audit Solution. It’s designed to ensure every line of business remains protected, audit-ready, and aligned with today’s intensified regulatory landscape.

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