CMS Accelerates RADV Audits: What Health Plans Need to Know Now

A Shift to Expanded Oversight

Historically, CMS selected approximately 60 Medicare Advantage contracts annually for contract-level RADV audits. Each audit reviewed a sample of about 35 members per plan. This limited sampling strategy allowed many MA plans to wager on the unlikelihood of audit selection, leading some to prioritize revenue-generating initiatives over audit preparedness.

The CMS announcement has significantly altered the outcome of this wager. CMS is now conducting RADV audits simultaneously across seven payment years for all MA contracts. Member samples per contract may range from 35 to over 200, depending on plan size. To support this expanded oversight, CMS is increasing its internal audit workforce from roughly 40 coders to a projected 2,000.

This expansion marks a dramatic operational shift. Rather than relying on random selection, CMS is moving toward near-universal audit participation, signaling a clear message that every Medicare Advantage plan is now subject to review. 

The May 30 Memo: New Deadlines

The accompanying May 30, 2025 memo introduces specific, non-negotiable deadlines for submitting closed-period deletes, diagnosis codes that were previously submitted but are now identified as inaccurate or no longer supportable. While plans can no longer add new codes for these closed payment years, they can remove erroneous ones.

The deadlines are as follows:

• PY 2020 – June 16

• PY 2021 – June 23

• PY 2022 – June 30

• PY 2023 – July 8

• PY 2024 – July 15

After these dates, CMS will temporarily pause the acceptance of deletes and data corrections. However, enforcement remains active. Plans are still legally required to report and return overpayments, regardless of whether CMS has temporarily halted correction submissions. This introduces a compliance tension; organizations must move quickly to clean up risk adjustment data or risk those inaccuracies being included in audit samples, subject to recoupment. 

Operational and Strategic Implications

For health plans, the challenges are immediate and significant. The RADV acceleration effort comes midway through the fiscal year, when budgets are already locked and staffing decisions have been made. Many plans have scaled down internal RADV teams in recent years, redirecting resources elsewhere. Now, they find themselves under-resourced precisely when CMS has intensified scrutiny.

The operational burden is compounded by audit complexity. Preparing defensible data submissions requires specialized expertise that many plans currently lack access to.

A Mindset Shift: From Revenue Generation to Revenue Protection

RADV has long been seen as a back-office function or a compliance formality. However, with the new CMS directive, audit readiness is no longer optional or viewed as a cost center. Plans must adopt an audit readiness mindset as a revenue protection strategy. Every accurate, properly documented, and defensible diagnosis represents revenue preserved. The cost of inaction is high, whether through recoupments or reputational damage. 

How UST HealthProof Can Help

CMS has raised the bar for oversight. Plans that respond strategically by investing in audit integrity, streamlining workflows, and partnering with experienced mitigation experts will be best positioned to navigate the new audit environment.

UST HealthProof specializes in helping health plans accelerate audit readiness and mitigate risk through a combination of highly knowledgeable experts, clinical expertise, technology, and process automation.  

UST HealthProof RADV support includes:

• Contract-level RADV simulation audits to identify high-risk conditions before they enter a CMS sample

• Closed-period diagnosis validation aligned to CMS submission deadlines

• Real-time dashboards and risk tracking to monitor deletes, reversals, and audit-sensitive codes across internal and vendor data sources

• End-to-end traceability of diagnosis codes for audit defensibility

• Expertise across audit types, including Part C IPM, OIG reviews, and CMS contract-level RADV

Contact us to learn how UST HealthProof can support your plan’s revenue protection strategy.