CMS to Expand RADV Audits Across All Medicare Advantage Plans: What Health Plans Need to Know
CMS is dramatically expanding its Risk Adjustment Data Validation (RADV) audits—scaling from 60 plans per year to over 550. With tighter timelines, AI-driven scrutiny, and larger record samples, here’s how health plans should prepare.
By Julie Hughes, Chief Compliance & Consultancy Officer, Imagenet
On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a significant expansion of auditing efforts for Medicare Advantage (MA) plans.
The initiative, which aims to clear a years-long audit backlog and enforce greater program integrity, will increase CMS’s reach from auditing ~60 plans per year to every eligible MA plan, starting with newly initiated audits. CMS will also invest additional resources to expedite the completion of audits for payment years 2018 through 2024.
Why Is CMS Expanding Audits?
Medicare Advantage plans receive higher payments for enrollees with more complex conditions, based on submitted diagnoses. To verify those diagnoses, CMS conducts Risk Adjustment Data Validation (RADV) audits.
However, CMS has fallen behind—its last major overpayment recovery followed an audit of PY 2007. Federal estimates suggest $17–43 billion in annual MA overpayments, with past audits (PYs 2011–2013) showing error rates of 5–8%.
To catch up, CMS has committed to completing audits for PYs 2018–2024 by early 2026.
What’s in CMS’s New RADV Audit Strategy?
To address the seven-year gap in Risk Adjustment Data Validation (RADV) audits, CMS has announced a multi-pronged strategy focused on technology, staffing, and expanded audit volume.
Use of Enhanced Technology:
CMS will use advanced systems to review medical records and flag unsupported diagnoses. Unlike past audits that used broad random samples, new audits may focus more narrowly on specific diagnosis codes or Hierarchical Condition Categories (HCCs), as allowed by current regulations.
Workforce Expansion:
To manage the increased audit volume, CMS plans to grow its team of medical coders from 40 to roughly 2,000 by September 1, 2025. These coders will manually review the flagged diagnoses to confirm accuracy.
Increased Audit Volume:
CMS will expand annual audits from around 60 to more than 550 MA plans—a 900% increase that will cover all eligible plans. Previously, plans that performed well in an audit were unlikely to be audited again soon. Going forward, CMS intends to audit all eligible contracts for each payment year. Record review will also expand—from 35 records per plan to 35–200, depending on plan size.
CMS also plans to work with the Department of Health and Human Services Office of Inspector General (HHS-OIG) to recover previously identified overpayments that have not yet been collected.
What This Means for Health Plans
The message from CMS is clear: every Medicare Advantage (MA) plan must be audit-ready—and soon. Key priorities include:
Ensuring medical record documentation fully supports submitted diagnoses
Identifying and addressing gaps in prior-year risk adjustment workflows
Strengthening coordination across coding, compliance, and documentation teams
Preparing to respond to record requests that may be 5–6x larger than in the past
CMS will pair expanded AI capabilities with a significantly larger human coding team, meaning plans should expect both more automation and more manual scrutiny.
CMS has announced key deadlines for deleting unsupported diagnoses in preparation for RADV audits covering Payment Years (PYs) 2020–2024.
Sampling is scheduled to begin in June 2025.
These deadlines represent the final opportunity to remove unsupported diagnosis codes before RADV sampling begins. Late submissions will not be accepted.
Effective immediately, Risk Adjustment Overpayment Reporting (RAOR) reporting for PYs 2020–2024 is suspended until notified by CMS. And, no additional deletes will be processed via RAPS or EDPS beyond the posted deadlines.
What Plans Should Do Now
With deadlines fast approaching, MA plans should:
Review MAO-004 reports to confirm diagnoses are supported by medical record documentation.
Identify and remove unsupported HCCs before the final delete deadlines.
Align internal audit and coding teams to ensure timely validation.
Monitor CMS updates regarding the resumption of overpayment reporting and corrections.
Understand that expediting this process on short notice is a significant administrative lift both for CMS and for all MA Plans.
Even plans with strong historical RADV performance should be prepared for a fundamentally different audit environment—one that demands deeper documentation integrity and stronger cross-functional coordination.
CMS Isn’t Waiting—Neither Should You
With CMS set to audit every eligible Medicare Advantage plan—across more years, more records, and more risk—it’s no longer a question of if you’ll be audited, but when. Unprepared plans may struggle to produce accurate documentation and face extrapolated findings that impact both revenue and reputation.
Now is the time to assess audit readiness, reinforce documentation controls, and align internal teams across risk adjustment, coding, compliance, and operations.
Imagenet is here to support that lift. Our team can assist with project management, administrative support, and quality review of proposed submissions – whether that means collecting records from providers, loading documents into the CMS system, preparing cover sheets, or quality review prior to final submission.
Contact us to learn how Imagenet can support your team with the technology and expertise needed to confidently navigate the new RADV audit environment.
CMS raised the bar. We’ll help you meet it—with confidence.
About the Author:
Julie Hughes serves as Chief Compliance and Consultancy Officer for Imagenet. She leads enterprise-wide compliance strategy and consulting services, with a focus on Medicare Advantage, FDR oversight, and regulatory readiness. Julie brings extensive expertise in building and optimizing compliance frameworks, fraud, waste, and abuse programs, and operational governance for health plans. Her background spans legal, administrative, and consulting roles, enabling her to drive integrated compliance solutions that support quality and performance. Julie holds a Juris Doctor from Temple University’s Beasley School of Law, a Master of Science in Healthcare Administration from St. Joseph’s University, and a BA in Anthropology and Sociology from Tulane University. She is also a Certified in Healthcare Compliance (CHC) and a Certified Professional Coder (CPC).