On January 27, 2026, the Centers for Medicare and Medicaid Services issued an important update clarifying the status of Risk Adjustment Data Validation audits [1]. The message is direct: RADV audits remain a top priority for ensuring the accuracy and integrity of Medicare Advantage payments, while CMS made operational adjustments based on stakeholder feedback.
This update arrives as MA organizations navigate both the accelerated audit timeline and uncertainty following the September 2025 court decision that vacated portions of the 2023 RADV Final Rule. With Payment Year 2020 audits now underway, Medicare Advantage organizations must understand where things stand and what actions to take now.
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What Is a RADV Audit and Why Does It Matter?
A RADV audit (Risk Adjustment Data Validation audit) is the process CMS uses to verify that diagnosis codes submitted by Medicare Advantage plans are supported by enrollees’ medical records [2]. During an MA RADV audit, CMS confirms whether the diagnoses that contributed to a health plan’s risk adjustment payment have proper clinical documentation.
The goal of a RADV audit is straightforward: ensure MA plans receive accurate payments based on their members’ actual disease burden. If diagnoses are unsupported by medical records, CMS may collect overpayments from audited contracts.
Federal estimates suggest that MA organizations may be submitting unsupported diagnosis data, resulting in approximately $17 billion in overpayments annually [3]. CMS completed audits for Payment Years 2011 through 2013 and found overpayment rates between five percent and eight percent, with recoveries beginning soon [1].
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Key Changes in the January 2026 CMS Update
The January 27, 2026, memorandum from CMS’s Audits and Vulnerabilities Group clarifies several changes to the MA RADV audit program. While implementing the accelerated audit strategy announced in May 2025, CMS adjusted operational parameters based on stakeholder feedback, separate from the ongoing Final Rule litigation.
Medical Record Submission Window Restored to Five Months
CMS restored the five-month medical record submission window for RADV audits, a significant change from the three-month window announced in May 2025. For PY 2019 RADV audits initiated in June 2025, CMS extended medical records deadlines to November 10, 2025 (Batch 1) and November 24, 2025 (Batch 2) [1].
Payment Year 2020 Audits Now Underway
CMS began PY 2020 RADV audits in February 2026 and will initiate future audits approximately every three months. CMS plans to publish a calendar describing the audit initiation cadence [1], allowing MA plans to plan for business needs.
Variable Sample Sizes and Medical Record Limits Clarified
CMS confirmed variable sample sizes of 35 to 200 enrollees based on contract size for PY 2020 and later RADV audits. Smaller contracts are less likely to receive the maximum sample [1]. The two medical records maximum per audited HCC remains in effect, with CMS emphasizing that only one valid record is needed to support payment.
AI Technology for Coder Support Coming
CMS plans to deploy artificial intelligence as a medical coder support tool to streamline human coding reviews [1]. All coding decisions affecting overpayment determinations will continue to be made by human certified medical coders. CMS will fully test this technology before implementation in RADV audits.
Quick Recap: How MA RADV Audits Evolved to This Point
The May 2025 CMS Strategy Announcement
In May 2025, CMS announced a strategy to expand and accelerate RADV audits [3], including:
- Concluding audits for Payment Years 2018 through 2024 on an expedited timeframe
- Expanding audits to all RADV eligible contracts (approximately 550 MA plans)
- Increasing sample sizes from 35 to 200 enrollees
- Reducing medical records per HCC from five to two
- Introducing AI technology to support accelerated audits
The 2023 RADV Final Rule introduced extrapolation methodology starting with PY 2018, meaning CMS could apply sample error rates across an entire contract population. However, on September 25, 2025, the U.S. District Court for the Northern District of Texas vacated portions of this rule, including the extrapolation provisions [4]. HHS appealed on November 21, 2025, and will comply with the court order while pursuing upcoming payment year audits [1].
Throughout Summer 2025, CMS met with industry stakeholders who expressed concerns about timing and operational burden. The January 2026 adjustments reflect that feedback.
How Often Are RADV Audits and Who Initiates Them?
MA RADV audits occur after the final risk adjustment data submission deadline for the MA contract year [2]. CMS, through its Center for Program Integrity, initiates all RADV audits for Medicare. Audit notices are sent through the Health Plan Management System. Questions should be directed to RADV@cms.hhs.gov.
Historically, CMS audited approximately 60 MA contracts per year. Under the accelerated strategy, CMS plans to audit all eligible MA plans annually (approximately 550 contracts) with a quarterly audit cadence.
Current RADV Audit Timeline and Key Deadlines
Payment Year | Status | Key Information |
PY 2011-2013 | Completed | 5-8% error rates; recoveries beginning soon |
PY 2018 | In progress | Methods & Instructions updated July 2025 |
PY 2019 | In progress | Medical records due November 2025 |
PY 2020 | Underway | Audits began in February 2026 |
PY 2021-2024 | Pending | To be completed per CMS timeline |
The Payment Error Calculation Methodology documents for PY 2011, 2012, and 2013 were published in early 2025 [2].
What Triggers a RADV Audit Selection?
CMS selects MA contracts for RADV audits considering multiple factors, including contracts with coding anomalies, outlier risk scores, or known compliance issues. Under the expanded audit program, all eligible MA plans face annual RADV audits, meaning selection is no longer about whether a plan will be audited but when.
Documentation Requirements That Support RADV Audit Success
Every diagnosis code submitted for risk adjustment must be supported by medical records demonstrating that the condition was actively managed during an encounter. The MEAT criteria (Monitored, Evaluated, Addressed, Treated) remain the standard for acceptable documentation [5].
Medical records must include:
- Valid face-to-face encounter documentation
- Clear provider credentials and a legible signature
- Date of service aligns with the payment year under audit
- Specific clinical evidence showing the diagnosis was actively managed
Common pitfalls leading to unsupported diagnoses include missing signatures, incomplete documentation of chronic conditions, coding historical conditions as active, and reliance on diagnoses not linked to patient encounters.
How the RADV Audit Process Works
The end-to-end RADV audit process follows four phases:
Phase 1: Notification and Preparation includes receiving audit notice via Health Plan Management System, downloading Enrollee Data List from CMS CDAT, assembling the audit response team, and establishing project milestones.
Phase 2: Chart Retrieval and Management involves generating chase lists, initiating provider outreach, receiving and organizing charts, and linking records to enrollees and HCCs.
Phase 3: Chart Review and HCC Validation requires certified coders conducting first-pass review, validating records against CMS MEAT criteria, performing quality assurance review, and identifying unsupported and potential “add” HCCs.
Phase 4: Submission and Post-Audit Activities includes selecting the best record for each validated HCC, formatting per CMS specifications, and managing rebuttal processes.
Financial Impact of RADV Audits on Medicare Advantage Plans
The financial consequences of RADV audits can be substantial. Under the 2023 Final Rule, CMS introduced an extrapolation methodology that would apply sample error rates across entire contract populations for PY 2018 and beyond. While the September 2025 court ruling vacated these extrapolation provisions from the Final Rule, fundamental financial exposure remains.
For audited contracts where unsupported diagnoses are identified, CMS collects overpayments. PY 2011-2013 audits found 5-8% error rates, providing a benchmark for potential exposure. Even without extrapolation, a 200-enrollee sample with significant unsupported diagnoses creates meaningful repayment demands.
Preparing for RADV Audits: A Strategic Framework
Given the accelerated audit cadence and increased scrutiny, Medicare Advantage organizations should adopt a continuous readiness posture.
Immediate Actions:
- Conduct internal chart audits using CMS criteria before CMS does
- Strengthen provider relationships now, as simultaneous record requests across MA plans create capacity strain
- Train coding teams on defensibility, not just accuracy
- Review claims data for potential deletes during CMS-provided windows
Technology Considerations: Manual processes cannot scale to meet annual RADV audits. MA organizations should evaluate workflow management tools, AI-powered validation for documentation risk identification, dashboards for leadership visibility, and integration with provider portals for efficient retrieval.
CMS Plans AI Support for RADV Audits
CMS has announced plans to use artificial intelligence as a support tool for medical coders during RADV audits [1]. This technology will help streamline coding reviews by flagging potential issues.
Key clarifications: AI will support, not replace, human-certified medical coders. All coding decisions affecting overpayments will be made by humans. The technology will be fully tested before implementation.
For MA organizations, this means audit reviews may identify documentation inconsistencies more efficiently than traditional manual review. Documentation practices must withstand machine-assisted scrutiny.
The Path Forward: Strategic Preparation Over Reactive Response
The January 2026 CMS update reinforces what Medicare Advantage organizations have understood since May 2025: RADV audits are accelerating, more predictable, and here to stay. Regardless of ongoing Final Rule litigation, the fundamental RADV audit process continues and CMS has committed to completing the backlog of audits through PY 2024.
The adjustments CMS made (restored submission windows, clarified sample sizes, published audit cadence) demonstrate responsiveness to stakeholder concerns while maintaining commitment to payment accuracy.
For MA plans, the strategic imperative is clear. Build audit response capabilities that can handle continuous oversight rather than one-time events. Invest in documentation practices that create defensible records from the start. Establish provider relationships and technology infrastructure that support swift, accurate medical record retrieval and validation.
The organizations that treat this as an operational transformation rather than a compliance exercise will be best positioned when the next payment year audit notice arrives.
Frequently Asked Questions About RADV Audits
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 goal is to ensure MA plans receive accurate payments based on documented diagnoses, protecting Medicare Trust Funds from overpayments.
Under the accelerated program, CMS plans to audit all eligible MA plans annually, with audits initiated approximately every three months.
CMS initiates all RADV audits through its Center for Program Integrity, Audits and Vulnerabilities Group.
Payment Year 2020 RADV audits began in February 2026 and are now underway.
MA organizations may submit a maximum of two records per audited HCC, though only one valid record is needed to support payment.
MA organizations may submit a maximum of two records per audited HCC, though only one valid record is needed to support payment.
CMS restored the five-month medical record submission window for RADV audits, providing more time to retrieve records from providers.
Documentation must show the diagnosis was actively managed during a face-to-face encounter with proper provider credentials, signature, and date of service meeting MEAT criteria.
Visit the CMS Medicare Advantage Risk Adjustment Data Validation Program page at cms.gov and direct questions to RADV@cms.hhs.gov.
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Wynda Clayton
Director of Risk Adjustment Coding & Compliance
Wynda Clayton serves as Director of Risk Adjustment Coding & Compliance at RAAPID. With over 20 years of experience in risk adjustment, coding, and compliance, Wynda is a seasoned RADV auditor and educator who focuses on maximizing coding accuracy while maintaining regulatory standards.
