2025 Contract-Level RADV Audit Updates

The CMS announcement signals a major shift in how Medicare Advantage (MA) plans will be audited, and it has serious implications for health plans, coders, and the entire risk adjustment industry. Here’s what it means: 1. Every MA Plan Will Be Audited Annually By leveraging technology, CMS will be able to increase its audits from ~60 MA plans a year to all eligible MA plans each year in all newly initiated audits (approximately 550 MA plans). CMS will also be able to increase from auditing 35 records per health plan per year to between 35 and 200 records per health plan per year in all newly initiated audits based on the size of the health plan. This will help ensure CMS’s audit findings are more reliable and can be appropriately extrapolated as allowed under the RADV final rule. 2. Massive Hiring of Medical Coders CMS is scaling up from 40 coders to 2,000 coders by September 1, 2025. These coders will manually review flagged diagnosis codes to ensure they are supported by documentation. 3. Bigger Audit Samples Instead of auditing just 35 records per plan, CMS may now audit up to 200 records per plan, depending on the size of the plan. This allows them to more accurately extrapolate overpayments using the RADV final rule. 4. Focus on Overpayments & Fraud CMS believes some MA plans are overbilling the government by $17B–$43B per year. These audits aim to recover overpayments and reduce fraud or abuse. 5. Real Financial Impact The announcement has already hit the stock prices of major insurers like UnitedHealth, Humana, and CVS—a sign that investors are worried about how much money health plans might have to pay back. 6. Enhanced Technology and HHS Oversight CMS will use new tools to scan medical records more efficiently, and it will work with the HHS Inspector General to collect past-due overpayments. Bottom Line for Coders and Plans: • Health plans must be very cautious about submitting accurate and well-documented diagnoses. • Coders will be under more scrutiny. • Unsupported diagnoses = financial risk. • Coding compliance and audit readiness are now top priorities for everyone involved in Medicare Advantage. If you’re in risk adjustment coding or auditing, this is a big deal. You’ll likely see more demand for accuracy, compliance, and audit support work. This goes right back to my Accuracy VS Production Article and how within some organizations they prioritize Production over Accuracy well News flash CMS got something for you!

🚀 CMS RADV Audits Surge in 2025 – What You Must Know 🔔 📈 Audit Scope Explosion: 🔹 Now: 550 Medicare Advantage (MA) plans audited annually 🔹 Before: ~60 plans per year ⬆️ That’s an 800% increase in audit coverage! 📊 Sample Size Growth: 🔹From: ~35 member records per plan 🔹To: Up to 200 records per plan ⬆️More charts = higher exposure for each organization 🕒 Accelerated Timelines: 🔹CMS targets completion of all RADV audits for PY 2018–2024 by early 2026 🔹Record requests arriving sooner than expected, with 12–20-week submission windows 💰 Extrapolation Risk: 🔹Findings for 2018+ payment years will be extrapolated across the full contract — increasing potential paybacks 📌 Note: A recent court ruling (Sept 2025) vacated parts of the 2023 RADV Final Rule — CMS response pending 👩💻 Massive Workforce & Tech Expansion: 🔹Coders: From ~40 ➜ 2,000 (by Sept 2025) 🔹Tech: CMS integrating AI/Machine Learning tools for chart review and unsupported diagnosis detection 📂 Impact on Plans & Providers: 🔹Huge rise in administrative workload for retrieving and validating charts 🔹Urgent need to tighten MEAT documentation, internal mock audits, and compliance education 🎯 Action Points for HCC Teams: ✅ MEAT - Ensure MEAT (Monitored, Evaluated, Assessed, Treated) is clearly supported in every note. ✅ Diagnoses - Validate that diagnoses were assessed during the encounter - not just listed. ✅ HCCs - Pay special attention to high-impact HCCs: CKD, CHF, Diabetes w/ complications, COPD. ✅ Provider Queries - Use clear, compliant provider queries when documentation is incomplete. ✅ Mock Audits - Participate in internal RADV mock audits — it sharpens coding quality and audit readiness. ✅ Compliance - Ensure HIPAA & coding compliance and stay current with annual coding updates. 🩺 Accurate documentation and precise HCC coding don’t just affect payment — they reflect true patient risk and care quality. #HCCCoding #RADVAudit #CMS #DocumentationIntegrity #MedicalCoding #CDI #CodersCommunity #RADVReadiness #CMSRADVUpdate #HCCUpdate #MedicareAdvantage #KalaiarasiSCoding #Compliance

🌟 New Medicare Advantage Risk Adjustment Guidance Released 🌟 On January 16, 2025, the new RADV Level 1 Reconsideration Guidance document was released, providing updates for Medicare Advantage Organizations (MAOs) on the Risk Adjustment Data Validation (RADV) audit dispute and appeal processes. Here are the key takeaways: ✔️ Three Appeal Levels: MAOs can appeal audit findings through three stages: reconsideration, hearing, and CMS Administrator review. ✔️ Reconsideration appeals must be submitted via CDAT within the 60-day window. ✔️ MAOs bear the Burden of proof in demonstrating that the MRRD and/or PEC decisions were incorrect. ✔️ MAOs must follow RADV rules, audit procedures, and appeals requirements to ensure their appeal is valid. ✔️ MAOs must complete the MRRD appeal before appealing the PEC. If only the PEC is appealed, the MRRD decision cannot be challenged later. 💡 Stay informed and prepared! This new guidance underscores the importance of compliance, timeliness, and strategy in navigating RADV audits. #MedicareAdvantage #RADV #CMS https://lnkd.in/gpZu4aEx

CMS is raising the bar on oversight Starting immediately, all eligible Medicare Advantage contracts will be audited annually in new CMS audit cycles—a dramatic escalation from the ~60 plans previously reviewed per year. What’s Changing: Audit Volume Surge: Audit sample size will increase from 35 to up to 200 records per plan per year, based on plan size. Massive Workforce Growth: CMS will scale its medical coder team from 40 to 2,000 by September 2025 to manually validate diagnoses. Tech-Driven Scrutiny: New AI-driven tools will assist in identifying unsupported risk-adjusted diagnoses. OIG Partnership: CMS will collaborate with HHS-OIG to recover historical overpayments. What This Means for Payors & Risk-Bearing Providers: The stakes are higher than ever. Risk-adjusted payments are under intense scrutiny—and operational gaps could result in significant financial and reputational exposure. Proactive Action Steps: 1. Audit Readiness: Reassess internal documentation and coding workflows—accuracy is non-negotiable. 2. Financial Contingency: Anticipate potential overpayment clawbacks—adjust reserves accordingly. 3. Risk Surveillance: Deploy analytics to identify audit-prone areas and proactively mitigate vulnerabilities. 4. Compliance Modernization: Update internal policies to align with CMS’s expanded audit framework. At Incuvio Health Inc, we help payors and providers stay ahead with scalable data strategies, audit-resistant documentation systems, and technology-enabled compliance support. Let’s talk if you’re preparing for the next wave of CMS scrutiny. #MedicareAdvantage #CMSAudit #ValueBasedCare #RiskAdjustment #RAF #MAPlans #HealthcareCompliance #RiskBearingEntities #IncuvioHealth #HealthTech

🚨 RADV audits just got real. 🚨 CMS has made it crystal clear: they’re coming for all 550 Medicare Advantage contracts — no exceptions, no hiding in the back row. And with billions of dollars on the line and error rates historically topping 9%, the stakes couldn’t be higher. That’s why I sat down for a 1.5-hour, no-holds-barred interview with Wynda Clayton, MS,RHIT — former RADV auditor, all around healthcare risk adjustment guru, and now Director of Risk Adjustment, Coding & Compliance at RAAPID INC. 🎯 We covered: ✏️ What CMS’ “audit everyone” directive really means for plans & providers ✏️ Key changes in methodology & timelines (hint: your 24-week prep window is history) ✏️ How to avoid the mistakes that trigger the biggest financial hits ✏️ The cutting-edge tools RAAPID INC has been building to make audit prep faster, smarter & less painful 💡 If you work in MA risk adjustment, this isn’t just “good to know” — it’s mission critical. The right tech + the right expertise can be the difference between sailing through an audit… and getting a bill you really don’t want to open. 🎥 Watch the full conversation — packed with insider tips, compliance pitfalls, and maybe a few “you can’t make this up” audit stories from Wynda’s career coming to your LinkedIn feed next week. Because when that audit letter comes, you’ll want to be the one smiling, not scrambling. #RADV #RiskAdjustment #MedicareAdvantage #CMS #HealthcareCompliance #VBC #RAAPID #HealthcareTechnology #AuditPrep #HealthcareOperations #ManagedCare #HCC #Audit #HealthcareLeadership