The September 25, 2025, court decision vacating CMS’s 2023 RADV Final Rule has created an unexpected strategic window for Medicare Advantage organizations. Judge Reed O’Connor of Texas’ Northern District vacated the Medicare Risk Adjustment Data Validation, or RADV, rule, determining that the CMS didn’t properly notify the industry about the changes in violation of the Administrative Procedures Act[1].
Yet PY2019 medical records submissions continue with November deadlines, and the underlying pressure remains: Federal estimates suggest MA plans may overbill the government by approximately $17 billion annually[2] according to CMS’s assessment.
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The Court Ruling: What Actually Changed (And What Didn’t)
The Immediate Impact
The court vacated the RADV Final Rule and remanded the matter to the agency for further consideration[3]. This means:
- Extrapolation methodology for PY2018 and beyond is suspended
- The Fee-For-Service Adjuster elimination is invalidated
- Current PY2019 audits continue, but without extrapolation threat
- Pre-2018 audits proceed as originally planned
What Remains Unchanged
Despite the ruling, several realities persist:
Ongoing PY2019 Deadlines: The extended November 2025 deadlines remain:
- Batch 1: November 10, 2025, for medical record submission
- Batch 2: November 24, 2025, for medical record submission
Documentation Requirements: MEAT criteria (Monitored, Evaluated, Addressed, Treated) still govern diagnosis codes submitted for validation.
Political Pressure: Top health regulators in the Trump administration have pledged to scrutinize the practice[1] of upcoding, signaling continued enforcement focus.
CMS’s Workforce Expansion: While CMS hasn’t achieved its goal of 2,000 medical coders by September 1, 2025, the agency continues building audit capacity through technology and staffing investments[2].
The Strategic Opportunity Window
Why This Pause Matters
The government has 60 days to appeal the decision to the 5th Circuit Court of Appeals[3]. This creates a unique preparation period where MA plans can strengthen compliance without immediate extrapolation pressure.
Consider this pause as preparation time, not celebration time. History shows regulatory reforms often return stronger after legal setbacks. The underlying issues driving audits—billions in questionable payments—haven’t disappeared.
Q4 2025: Your Action Framework
Immediate Actions (October 2025):
Complete PY2019 submissions despite uncertainty. CMS selected 45 MA contracts in the first batch of PY 2019 RADV audits, including several of the nation’s largest Medicare Advantage organizations.
Documentation Enhancement: The compression remains real—MAOs now have just 12 weeks to respond instead of the previous 22 weeks[5] and may now only submit up to two records per HCC under review, down from the five records allowed in previous audits[5].
Technology Implementation (November 2025):
Deploy validation systems while regulatory pressure is reduced. Organizations implementing human-augmented AI solutions now will be ahead when enhanced audits return.
Strategic Planning (December 2025):
Model scenarios for revised rules. CMS could address this court decision in upcoming webinars with plan representatives[3], potentially revealing new approaches.
Understanding the Technology Evolution
Moving Beyond Traditional NLP
Natural Language Processing (NLP) remains valuable for extracting clinical information—identifying diagnoses, medications, and provider details in unstructured text. NLP excels at the “what” of documentation.
However, RADV audits require understanding the “why” and “how”—determining whether identified diagnoses meet MEAT criteria. This requires:
- Contextual reasoning: Was diabetes actively managed or just mentioned historically?
- Temporal understanding: Does documentation support current treatment?
- Compliance validation: Are all required elements present and linked?
The Human-Augmented AI Advantage
Modern solutions combine NLP’s extraction capabilities with reasoning technology that mimics expert auditor judgment. Think of it as:
AI as Super-Reader: Processes hundreds of pages in seconds, flagging potential issues and opportunities.
Humans as Decision-Makers: Certified coders review AI findings, applying expertise and judgment.
Pre-Trained Excellence: Developed using extensive historical validation data, the system provides consistent, reliable accuracy without using client information for training.
This partnership achieves 98% accuracy—significantly exceeding the 70% typical of NLP-only approaches—while reducing review time from 30-40 minutes to under 8 minutes per chart.
RAAPID’s Strategic RADV Solutions
Understanding that Medicare Advantage organizations face different challenges, RAAPID offers two targeted approaches:
Solution 1: Audit Management Tool
For organizations with strong coding teams needing workflow optimization:
Purpose: Centralizes your entire RADV audit process in one platform, eliminating spreadsheet chaos and email confusion.
Core Benefits:
- Automated chase list generation prioritizing medical records retrieval
- Real-time dashboards provide instant visibility into submission status
- Automatic HCC tracking ensures nothing falls through the cracks
- CMS-compliant reports are generated with one click
Ideal For: Plans with established teams seeking efficiency gains and better oversight.
Solution 2: AI-Augmented Full-Service Solution
For organizations needing comprehensive support during this transition:
Purpose: Combines advanced technology with certified audit experts who partner with your team.
Core Features:
- AI pre-validates charts against MEAT criteria, flagging concerns
- Expert auditors provide second-level validation
- Intelligent prioritization identifies the best records for submission
- Complete audit defense documentation prepares you for appeals
Ideal For: Plans facing immediate deadlines or building RADV capabilities.
The Explainable AI Difference
When we discuss “Neuro-Symbolic AI,” we’re describing technology that combines:
Pattern Recognition: Like experienced coders who instantly recognize documentation patterns indicating active treatment—learned from millions of records.
Rule Application: Like coders applying CMS guidelines consistently—if documentation shows MEAT criteria, the diagnosis validates.
The critical advantage: transparency. For every validation, you see:
- Source document location
- Supporting text evidence
- MEAT criteria satisfaction
- Clear pass/fail reasoning
This creates defensible audit readiness with clear documentation trails for every code.
Autonomous Retrospective Risk Adjustment Solution
One platform. Every HCC validated. Revenue secured.
Financial and Operational Preparation
Understanding Continued Risk
Despite the ruling, financial exposure remains:
Current Audits: PY2019 audits continue without extrapolation but still require responses.
Future Rules: CMS will likely revise and reissue rules addressing court concerns.
OIG Oversight: The Office of Inspector General continues identifying questionable payments[6], maintaining enforcement pressure.
Building Resilience Now
Reserve Planning: While extrapolation is paused, model 5-8% error scenarios for future preparedness.
Documentation Excellence: Use this window to strengthen provider education and documentation practices.
Technology Investment: Implement solutions while pressure is reduced, avoiding crisis implementations later.
The Path Forward: Strategic Recommendations
For MA Plans Under Current Audit
Complete PY2019 submissions on schedule despite uncertainty. Documentation requirements haven’t changed, and non-response creates worse outcomes than imperfect submissions.
For Medicare Plans Not Yet Audited
This is your preparation opportunity. Conduct mock audits using current standards, identify documentation gaps, and implement corrective measures before selection.
For All MA Organizations
View this pause as transformation time. Organizations using this window to implement human-augmented AI solutions, strengthen documentation practices, and build compliance infrastructure will thrive when enhanced oversight returns.
Conclusion: From Uncertainty to Opportunity
The September 2025 court ruling creates breathing room, not permanent relief. Judge O’Connor emphasized that notice and comment is not a box-checking exercise[7], suggesting CMS will return with properly structured rules.
Smart Medicare Advantage plans recognize this window for what it is: time to transform compliance from reactive scrambling to proactive excellence. Organizations implementing advanced validation technology, strengthening documentation practices, and building robust audit infrastructure now will convert regulatory uncertainty into competitive advantage.
As CMS rolls toward revised enforcement approaches, the question isn’t whether enhanced RADV audits will return—it’s whether your organization will be ready with defensible documentation and efficient processes when they do.
The clock is ticking on this strategic window. Organizations acting decisively now will thank themselves when the next wave of audit requirements arrives.
TL;DR:
A federal judge has thrown out the Biden-era rule that would have clawed back billions of dollars in overpayments from Medicare Advantage insurers[1]. While this September 2025 ruling creates temporary relief, RADV audits continue for PY2019 with November deadlines approaching. Smart Medicare Advantage plans are using this window to strengthen documentation, implement AI-augmented validation tools, achieving 98% accuracy, and prepare for inevitable regulatory reforms. The question isn’t if enhanced audits will return—it’s whether you’ll be ready when they do.
Frequently Asked Questions
A RADV audit (Risk Adjustment Data Validation) verifies that diagnosis codes submitted by Medicare Advantage plans are supported by medical documentation, ensuring diagnoses meet MEAT criteria for appropriate risk-adjusted payments.
The ruling vacated CMS’s 2023 Final Rule[8], suspending contract-level extrapolation and the elimination of the FFS Adjuster for PY2018 and beyond, though current audits continue.
Yes, PY2019 audits proceed with November 2025 deadlines, though without extrapolation threat pending regulatory resolution.
The Centers for Medicare & Medicaid Services conducts RADV audits through their Center for Program Integrity, while the Office of Inspector General performs separate compliance reviews.
Documentation must show face-to-face encounters with clear evidence of conditions being Monitored, Evaluated, Addressed, or Treated, including valid provider signatures and credentials.
CMS selects contracts, requests medical records for sampled enrollees, reviews documentation for MEAT compliance, and calculates error rates to determine payment accuracy.
Batch 1 plans must submit medical records by November 10, 2025; Batch 2 by November 24, 2025, with earlier hardship exception deadlines.
The government has 60 days to appeal to the 5th Circuit Court of Appeals, with decision expected by late November 2025.
Strengthen documentation practices, implement validation technology, conduct mock audits, and prepare for revised regulations likely to emerge.
Human-augmented AI solutions combining NLP extraction with reasoning capabilities achieve 98% accuracy while creating explainable audit trails for every diagnosis.
MEAT documentation proves diagnoses were actively managed during encounters, not just historical conditions, ensuring appropriate payment validation[9].
Yes, use this window to strengthen compliance infrastructure. Enhanced oversight will likely return with revised regulations.
RAAPID offers workflow management tools for established teams and full-service solutions combining AI technology with certified auditors, achieving 98% accuracy while reducing review time by 75%.
These remain uncertain pending CMS guidance[10], though preparation for multiple payment year audits remains prudent.
While timing is uncertain, the underlying issues driving audits—billions in questionable payments—ensure enhanced oversight will return in revised form.
Source
[3] Crowell & Moring LLP – Court Vacates CMS’s 2023 Final Rule on RADV Audits (September 25, 2025)
[4] The Healthcare Labyrinth – RADV Audit Methods And Instructions Published (June 28, 2025)
[5] CMS – Payment Year 2019 RADV Questions and Answers (Updated June 26, 2025)
[6] HHS Office of Inspector General – Medicare Advantage Questionable Use of Health Risk Assessments
[7] National Law Review – Texas Court Strikes Down CMS’s RADV Rule (September 2025)
[8] Federal Register – 2023 Final Rule Medicare and Medicaid Programs Policy Changes
[9] CMS – Contract-Level RADV Medical Record Reviewer Guidance (January 2020)
[10] CMS – Medicare Advantage Risk Adjustment Data Validation Program
About the author
Wynda Clayton
Director of Risk Adjustment Coding & Compliance
Wynda is a recognized leader with over 20 years of experience in risk adjustment, coding, and compliance. A seasoned RADV auditor and educator, she focuses on maximizing coding accuracy and maintaining regulatory standards. At RAAPID, Wynda spearheads AI-driven initiatives to enhance value-based care delivery and reimbursement accuracy.
