From RADV Audits to Utilization Concerns, Medicare Advantage Insurers Chart Uncertain Path

Jul 17
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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Lauren Flynn Kelly

Lauren has been covering health business issues since the early 2000s and specializes in in-depth reporting on Medicare Advantage, managed Medicaid and Medicare Part D. She also possesses a deep understanding of the complex world of pharmacy benefit management, having written AIS Health’s Radar on Drug Benefits from 2004 to 2005 and again from 2011 to 2016. In addition to her role as managing editor of Radar on Medicare Advantage, she oversees AIS Health’s publications and manages the health editorial staff. She graduated from Vassar College with a B.A. in English.