CMS Ramps Up RADV Audit Plans, But Questions Remain About Process
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Jun 05, 2025
Following up on promises to root out fraud, waste and abuse in government-sponsored programs, CMS on May 21 stunned the industry with a bold plan to rapidly expand risk adjustment data validation audits (RADV) used to collect overpayments from Medicare Advantage plans. And on May 30, CMS informed all MA organizations that they have until June 16 to make corrections to their risk adjustment data for payment years 2020 to 2024, before CMS starts pulling samples for the RADV audits it intends to complete early next year.
That means MAOs have mere weeks to submit “deletes” for any data that doesn’t support the hierarchical condition categories (HCCs) they’ve submitted for risk adjustment, and compliance experts suggest plans pay particularly close attention to the data behind select “high-risk” diagnosis codes. At the same time, they are urging plans to brush up on the basics of RADV and to make sure they and their vendors are following the appropriate risk adjustment policies and procedures.
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