From RADV Audits to Utilization Concerns, Medicare Advantage Insurers Chart Uncertain Path
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Jul 17, 2025
Since President Donald Trump’s return to the White House, CMS has been clear about its goals of rooting out fraud, waste and abuse. For Medicare Advantage organizations, that means an expansion of Risk Adjustment Data Validation (RADV) audits, which present operational burdens and potential financial implications for plans. But that’s just one key area of uncertainty that industry observers are watching in the second half of 2025. How can MA organizations keep calm and carry on?
“There is quite a lot of uncertainty in this market currently and as such, ‘carrying on’ should not mean doing the minimum when it comes to successfully operating an MA plan. Sitting idle in MA is not an option,” advises Julia Friedman, principal and consulting actuary with Milliman. “MAOs need to ensure they are well ahead of compliance and documentation, doubling down on quality and [Star Ratings] metrics, and investing in appropriate utilization management programs. Organizations that truly prioritize integration — both working through intra-departmental integration as well as externally pushing investments in integration of data-driven clinical, pharmacy, and provider relationships — will set themselves up for success.”
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