In May 2025, the Centers for Medicare & Medicaid Services (CMS) announced a Risk Adjustment Data Validation (RADV) audit program overhaul.
CMS will begin auditing every eligible Medicare Advantage (MA) plan each year, rather than focusing on a limited sample. This changes how CMS monitors the accuracy of diagnosis coding and risk adjustment in the MA program.
For healthcare practices, especially those in value-based or risk-sharing arrangements, this shift introduces new and immediate risks. Practices will likely face increased demands for medical records, greater scrutiny of documentation, and a higher risk of payment clawbacks.
This article breaks down what healthcare providers need to know about the RADV program’s expansion and how practices can prepare.
Key Takeaways
- Annual audits for all plans: CMS will now audit all 550 eligible Medicare Advantage contracts each year, up from a previous average of 60.
- Larger record samples: The number of records CMS will review per plan will increase to as many as 200 annually. This raises the chances of specific documentation facing scrutiny.
- Audit backlog completion: CMS aims to complete all outstanding RADV audits for Payment Years 2018 through 2024 by early 2026.
- Retroactive clawback risk: Medicare Advantage plans may seek to recoup payments from providers if CMS identifies unsupported diagnoses, especially in shared savings or capitated arrangements.
- Strict documentation standards: Minor errors such as missing provider signatures, vague language, or unsupported diagnoses can lead to disallowed codes and repayment demands.
RADV Timeline at a Glance
| Date | Milestone |
| May 21, 2025 | CMS announces RADV program expansion |
| Sept 1, 2025 | CMS plans to increase audit workforce to 2,000 coders |
| Early 2026 | CMS expects complete audit backlog of PY 2018-PY 2024 |
Understanding RADV Audits and Their Purpose
The Centers for Medicare & Medicaid Services (CMS) conducts Risk Adjustment Data Validation (RADV) audits. They verify the accuracy of diagnosis codes submitted by Medicare Advantage (MA) plans. These codes determine patient risk scores, which directly influence the amount that CMS pays each MA plan for each enrollee.
The risk adjustment model aims to provide higher payments for members with complex health conditions. To calculate these payments, MA plans submit diagnosis codes collected from provider medical records. CMS expects providers to support each code with clear clinical documentation. This must show that the condition was present, evaluated, and addressed during a patient encounter.
RADV audits assess whether the submitted diagnosis codes meet this standard.
During an audit, CMS requests a sample of medical records from an MA plan. Certified coders review these records to determine if the documentation supports the diagnoses that contributed to the enrollee’s risk score. If a provider does not properly document a diagnosis, CMS considers it invalid and may classify the related payment as an overpayment.
To support a diagnosis code in a RADV audit, the provider’s documentation must meet specific criteria. This includes identifying the condition by name, providing evidence that it was evaluated or treated, and ensuring the record is signed and dated by a credentialed provider. Records that are incomplete, vague, or missing key elements may result in the disallowance of the diagnosis.
The audit process typically includes notice to the MA plan, a period for record submission, a formal review, and the potential for repayment if CMS finds errors. While CMS conducts these audits at the plan level, the supporting documentation comes directly from provider records. This makes provider compliance and documentation accuracy critical components of a successful RADV audit outcome.
Why Are RADV Audits Changing?
The expansion of the RADV program is driven by increased federal concern about the accuracy and sustainability of Medicare Advantage (MA) payments.
According to this MedPac Report, the MA program covered more than 33.1 million beneficiaries in 2024 and paid over $453 billion to MA plans in 2023. As the program has grown, so has scrutiny of payment calculations.
CMS has identified problems with unsupported diagnosis codes used to determine patient risk scores. These can lead to overpayments from CMS to MA plans. According to federal estimates, MA plans may be overbilling the program by as much as $17 billion each year.
To address these concerns, CMS is intensifying its efforts to ensure that all submitted diagnoses are backed by valid clinical documentation. By expanding the RADV program, CMS aims to improve payment accuracy, reduce fraud and waste, and protect the long-term financial integrity of the MA program.
What’s Changing in 2025 for RADV Audits?
CMS’s May 2025 announcement introduced several major policy shifts that affect how audits are conducted, how fast they occur, and the scale of documentation expected.
Annual Audits for All Medicare Advantage Plans
- CMS will now audit all eligible Medicare Advantage plans each year, totaling approximately 550 contracts.
- Previously, audits were limited to a small group of plans flagged as outliers based on risk or statistical indicators.
- As a result, practices working with multiple MA plans can expect more frequent and routine documentation requests.
Faster Completion of Backlogged Audits
- CMS will complete all RADV audits for Payment Years 2018 through 2024 by early 2026.
- These audits will apply the agency’s extrapolation policy. This allows CMS to estimate overpayments from a sample of records and apply the findings across the full plan population.
- CMS has not yet disclosed its specific extrapolation methodology, raising concerns about statistical fairness and provider exposure.
Larger Sample Sizes in Each Audit
- The number of records reviewed per MA plan will increase from approximately 35 to up to 200.
- This larger sample is intended to improve statistical reliability, but it also raises the chances of identifying unsupported diagnoses.
- The increased sample size significantly expands the documentation workload for both MA plans and provider organizations.
Expansion of Technology and Audit Staff
- CMS is increasing its RADV workforce from 40 to roughly 2,000 coders by September 2025.
- The agency also plans to use artificial intelligence and machine learning tools to identify unsupported diagnoses in medical records.
- CMS has not yet provided specific details on how it will deploy these tools. This raises concerns about audit transparency, reliability, and due process protections for providers.
What the RADV Changes Mean for Healthcare Practices
The expansion of the RADV program will have a direct impact on healthcare providers, particularly those serving large Medicare Advantage populations or participating in risk-based contracts.
Although audits are conducted at the plan level, MA plans rely heavily on provider documentation to support the diagnosis codes that drive their payments. As a result, providers may face financial, operational, and contractual consequences tied to RADV findings.
Increased Risk of Clawbacks
Many Medicare Advantage contracts contain clauses that allow plans to recover payments from providers if CMS identifies overpayments during an audit. These clawbacks may apply retroactively and can result in significant financial exposure.
Although CMS conducted relatively few Medicare Advantage audits before 2019, enforcement activity has increased significantly in recent years. In 2021 alone, CMS recouped more than $223 million in overpayments from just six Medicare Advantage plans.
In 2022, CMS recovered another $134.7 million from twelve Medicare Advantage plans, reinforcing the agency’s growing focus on audit-based enforcement and financial accountability.
Smaller practices may be particularly vulnerable, as they may not have the reserves to absorb sudden losses or withheld payments. Proactive risk management, including chart audits and contract review, is essential to limit exposure.
Greater Documentation Pressure
Medical records must meet specific standards in order to support the diagnosis codes submitted by MA plans. If records do not meet these criteria, CMS may disallow the code and treat the payment as an overpayment.
CMS expects:
- Clear evidence that the diagnosis was evaluated or treated during the encounter: Medical records must document that the diagnosis was evaluated or treated during a specific face-to-face visit. CMS guidance states audits use “medical record documentation of a single face-to-face encounter for physician/practitioner office and hospital outpatient visits”
- Documentation that is signed, dated, and includes the provider’s credentials: Records must include a legible signature and date from the credentialed provider. CMS reviewer guidance specifies a valid medical record for RADV “must be legibly signed and dated by a provider with an appropriate risk adjustment physician specialty”
- Alignment between encounter notes, coding submissions, and problem lists: Documentation must consistently support submitted diagnosis codes. CMS mandates that records be reviewed according to official ICD conventions and must clearly support audited HCCs
Even small errors, such as missing signatures or vague documentation, can result in disallowed codes.
Increased Stress on HIM Teams
The expanded RADV program places a significant burden on Health Information Management (HIM) teams, who are on the front lines of responding to audit-related documentation requests. As CMS ramps up audit frequency, expands sample sizes, and accelerates review timelines, HIM departments will face growing pressure to locate, review, and submit large volumes of records accurately and quickly.
This operational load presents multiple challenges:
- Higher Volume of Record Requests: With up to 200 records requested per plan per year and all 550+ Medicare Advantage plans subject to annual audits, HIM teams supporting multiple plans may be asked to retrieve hundreds of records with minimal lead time.
- Tighter Turnaround Windows: CMS allows 25 weeks for full documentation submission, but MA plans may require faster internal timelines to meet their compliance obligations. HIM staff must manage these deadlines while continuing to support other core functions like continuity of care, patient requests, and internal audits.
- Greater Scrutiny on Record Quality: Records must meet CMS audit standards, including clear diagnosis support, complete provider credentials, proper dates, and legibility. HIM professionals must review each chart carefully to ensure compliance before submission, often under pressure.
Without added support, HIM departments may become a bottleneck in audit response efforts, increasing organizational risk. Proactively bolstering HIM capacity is essential to protecting both compliance and revenue.
Examples of High-Profile FCA Fines and Settlements
RADV audits carry more than administrative or financial consequences. When CMS identifies patterns of unsupported diagnosis codes, it may refer those findings to the Department of Justice (DOJ).
These referrals can lead to enforcement actions under the False Claims Act (FCA). These often result in multimillion-dollar settlements or penalties for both health plans and providers.
Recent high-profile cases include:
- Sutter Health agreed to pay $90 million to settle allegations that it violated the False Claims Act by knowingly submitting unsupported diagnosis codes for Medicare Advantage patients, resulting in inflated payments.
- Cigna agreed to pay over $172 million to resolve allegations that it violated the False Claims Act by submitting and failing to correct inaccurate diagnosis codes for its Medicare Advantage enrollees.
- Independent Health Association and its affiliate agreed to pay up to $98 million to resolve allegations that they violated the False Claims Act by submitting unsupported diagnosis codes to inflate Medicare Advantage payments. The settlement includes a $34.5 million guaranteed payment, up to $63.5 million in contingent payments, and a $2 million payment by DxID’s founder.
These cases illustrate how legal liability may extend beyond plans to providers and third-party vendors. Even if a provider is not the primary target, inadequate documentation or improper coding practices can trigger audits, recoupments, reputational harm, and litigation.
What Steps Can Healthcare Professionals Take?
To prepare for the expanded RADV audit program, healthcare practices should take proactive steps to reduce risk, improve documentation accuracy, and build internal capacity to respond quickly to record requests.
1. Conduct Internal Documentation Reviews
Start by auditing medical records for patients covered under Medicare Advantage, especially those in risk-sharing or capitated arrangements. Focus on high-volume or high-risk cases where coding complexity may be greater.
When reviewing records, check for:
- Diagnoses that lack clinical evidence or are not clearly assessed, treated, or monitored during the encounter
- Missing signatures, dates, or credentials that invalidate the record under CMS audit standards
- Overuse of templated or cloned notes, which may signal a lack of individualized care
- Inconsistent problem lists, especially when conditions appear in billing but not in clinical documentation
If your team identifies issues, correct them within allowable timeframes and document the actions taken. Keeping a record of remediation efforts demonstrates a commitment to compliance and may help during future audits.
2. Train Staff on RADV Readiness
Educating providers, coders, and administrative staff is essential to reduce the risk of diagnosis-related errors during a RADV audit. Everyone involved in documenting, coding, or managing patient records should understand how CMS evaluates audit validity and what constitutes compliant documentation.
Effective RADV training should include:
- What qualifies as a valid diagnosis under CMS guidelines, including documentation that shows a condition was evaluated, monitored, or treated during the visit
- How to properly support common chronic and acute conditions with specific, non-templated clinical notes that align with the diagnosis code
- When and how to use addenda or amendments to clarify the medical record without violating CMS or payer documentation rules
- Common reasons diagnosis codes are disallowed, such as missing signatures, uncredentialed providers, vague terminology, or copy-paste errors
Integrate RADV readiness into annual compliance programs and new hire onboarding. Use real-world examples, coding audits, and chart reviews to reinforce best practices. Ongoing education helps ensure that documentation practices are consistent, defensible, and aligned with evolving audit expectations.
3. Strengthen Your Record Retrieval Workflow
CMS typically requires providers and Medicare Advantage plans to submit requested medical records within 25 weeks of receiving a RADV audit notice. While this timeline may seem manageable, retrieving records from multiple systems, validating them, and ensuring audit-ready quality can become overwhelming as audit volume grows.
Practices need a reliable, repeatable process to gather and submit documentation quickly and accurately. To prepare, healthcare practices should:
- Establish a centralized system for tracking audit-related documentation requests, submission deadlines, and responses
- Designate responsible personnel or a small team to manage record collection, quality control, and communications with plans or auditors
- Train clinical and administrative staff on documentation standards required by CMS, including proper formatting and completeness for audit submission
- Standardize documentation workflows with checklists or quick-reference guides to ensure records meet audit expectations before submission
- Leverage third-party platforms or release of information vendors with proven audit capabilities
With built-in tracking, workflow automation, and compliance safeguards, ChartRequest helps reduce administrative pressure and improve audit readiness. Practices using ChartRequest can meet RADV deadlines more efficiently without adding or overwhelming staff.
Ease the Administrative Burdens of Audit Requests
The RADV program overhaul represents a fundamental change in how CMS audits and enforces the accuracy of diagnosis coding in Medicare Advantage.
For healthcare providers, this shift introduces new layers of financial, administrative, and legal responsibility. Practices must prepare for increased audit volumes, stricter documentation standards, and rising contractual risks.
While preparation cannot eliminate the challenges of RADV audits, it can help ensure that your practice remains compliant, responsive, and financially stable as the program scales up.
ChartRequest helps healthcare organizations respond quickly and securely to audit record requests, with automated workflows that reduce administrative burden and ensure timely compliance.
Our solutions support providers through complex medical record audits, so your team can focus on delivering quality care.
Find out if ChartRequest is right for your organization with a personalized consultation.
