RADV Audits Are Accelerating: How Medicare Advantage Plans Can Stay Ahead of Compliance Risks

Key Takeaways

• CMS is expediting RADV audits and clearing a seven-year backlog, increasing both oversight and urgency for Medicare Advantage plans.
• Every MA contract will now undergo annual RADV review, raising the financial and operational exposure from unsupported risk adjustment data.
• Pandemic-era documentation variability and staffing/system changes heighten the challenge of retrieving historical clinical evidence.
• Proactive compliance — not retrospective clean-up — is now essential to mitigate extrapolated repayments and protect risk-adjusted revenue.
• Strong operational controls such as documentation governance, provider education, real-time HCC validation, and RADV simulation audits define organizational readiness.
• Partnering with specialized experts enables year-round audit preparedness, stronger documentation integrity, and defensible coding outcomes.

A New Era of Risk Adjustment Scrutiny

Risk Adjustment Data Validation (RADV) audits have always been a cornerstone of Medicare Advantage (MA) oversight — but historically, unpredictability and lengthy delays muted their impact. CMS is now changing that reality.

The agency has committed to conducting RADV audits on all MA contracts every year, while simultaneously clearing a significant backlog of audits dating as far back as 2018–2024. This shift brings greater transparency and accountability — but also dramatically higher financial stakes.

CMS has clearly signaled that effective risk adjustment must be based on valid and defensible clinical data. That means MA plans are now operating in a compliance environment where every coding decision matters.

Why RADV Audits Are Intensifying

Several forces are driving this enforcement shift:

• Explosive MA enrollment growth → larger federal spend, higher public scrutiny
• Variation in coding practices → concerns over risk score inflation
• Pressure from OIG and policymakers → stronger recovery of overpayments
• CMS’s focus on payment integrity → move toward real-time oversight

The result? A compliance strategy that was “good enough” five years ago is now a major liability.

The Opportunity: Predictability and Fairness

More timely and frequent audits create:

Greater clarity for financial forecasting

Audits aligned to the prior performance year enable faster feedback loops and more accurate actuarial modeling.

A level playing field

Consistent validation ensures compliant plans aren’t disadvantaged by those relying on aggressive coding.

Reinforcement of accurate care documentation

Ensuring risk adjustment reflects true patient complexity improves equity in reimbursement.

When risk is visible and timely — leadership can plan, correct, and invest more confidently.

The Challenge: Higher Exposure and Operational Strain

With every contract audited and findings extrapolated, even small documentation errors could compound into massive repayment demands.

Additional risks include:

• Seven years’ worth of data requests compressed into tight turnaround periods
• Complex records spanning different staff, systems, and documentation standards
• Inconsistent EHR and coding practices during pandemic-era care delivery

For many MA plans, these audits represent the most significant compliance threat they’ve ever faced.

The Wildcard: The Practical Uncertainties

RADV audits bring questions without clear answers:

• Can CMS realistically review multiple years of claims and clinical records at scale?
• Will pandemic-era documentation flexibility impact audit outcomes?
• How will leadership turnover impact the ability to defend historical coding decisions?

Many plans may struggle to retrieve required documentation for older encounters — especially those involving physicians who no longer participate with the organization.

Where Extrapolation Complicates Everything

Small Sampling + Extrapolation = Exponential Financial Impact.

If 10% of diagnoses in a sample are found invalid → CMS may categorize 10% of the year’s payments as overpayments.

However, longstanding debates continue:

• Normalization factors, designed to neutralize industry-wide coding trends, have already adjusted payments.
• Should retrospective extrapolation account for these adjustments?
• Could compliant plans be doubly penalized?

Legal challenges historically slowed RADV enforcement for these very reasons — and the healthcare legal community expects new litigation in coming years.

One thing is certain: the government will aggressively pursue improper payments.

How Plans Can Mitigate RADV Risk Right Now

Proactive risk adjustment compliance is no longer optional. Winning strategies include:

1. Strengthen Documentation Integrity

Real clinical conditions → supported by clear, specific, and current evidence within the chart.

2. Conduct Prospective Chart Reviews

Identify missing diagnoses and documentation gaps before claims flow through.

3. Deploy AI-driven Compliance Technology

Advanced analytics can flag unsupported conditions, ICD-10 specificity issues, and recapture opportunities.

4. Invest in Provider Education

Physicians must understand the downstream impact of clinical language on risk scoring.

5. Treat RADV Like a Real-Time Initiative

Year-round data validation is now the expectation — not a cleanup task years later.

Plans that modernize will not only survive increased scrutiny — they will outperform competitors.

In the End, RADV Is About Integrity and Equity

Medicare Advantage relies on fair allocation of a fixed budget. When one plan receives inaccurate overpayments, fewer resources remain to support others — including those caring for the most vulnerable.

RADV audits reinforce trust in the system.

Timely accuracy benefits everyone: CMS, plans, providers, and — most importantly — the beneficiaries they serve.

Preparing for RADV Success Starts Now

Medicare Advantage organizations can’t afford a “wait and see” approach as CMS accelerates audits and tightens enforcement. Ensuring compliant risk-adjusted revenue requires more than retrospective fixes — it demands strong documentation governance, clinical validation, and continuous oversight.

This is where expertise makes all the difference.

At Bristol Healthcare Services, we bring:

• Documentation Integrity Excellence

  Ensuring every reported condition is linked to accurate, specific, and up-to-date clinical evidence.

• Specialized Risk Adjustment Coding

  Certified coders with deep HCC knowledge that supports defensible risk scores while optimizing reimbursement.

• RADV-Focused Chart Audits & Compliance Support

  Targeted audits that uncover vulnerabilities early, strengthen provider documentation habits, and reduce the threat of extrapolated recoupments.

We help Medicare Advantage plans stay audit-ready year-round — not scrambling when the notice arrives.

With a proven track record of 99% coding accuracy, scalable chart review resources, and advanced analytics, we empower payers to confidently navigate CMS’s heightened oversight while safeguarding every earned dollar.

Take Control of Your Compliance Future

The new RADV environment rewards those who invest in accuracy and transparency today. Let’s build a risk adjustment program that performs — even under the microscope.

Schedule a consultation today to discuss your RADV preparedness and coding compliance strategy.

Together, we can strengthen your documentation integrity, reduce exposure, and ensure the right care receives the right reimbursement — every time.

Click the link to learn more about our medical coding services and explore our range of end-to-end revenue cycle management services.