Host: Welcome to a special bonus episode in response to the recent CMS announcement on RADV acceleration for Medicare Advantage plans. If you’re in risk adjustment, compliance, or just trying to protect revenue, this is for you. To help us understand the implications of this announcement, we’re joined by Amanda Proctor, Director of Coding Quality and Risk Mitigation at UST HealthProof. Amanda has deep expertise in risk adjustment audit preparedness and has guided numerous plans through RADV, OIG, and Part C audit cycles. She brings sharp insights into what this acceleration really means and how health plans can respond. Amanda, thanks for being here.
Amanda: Thanks for having me. It’s a landmark shift for the industry, and I’m glad we’re having this conversation.
Host: Let’s begin with foundational context. Medicare Advantage plans undergo different forms of audit and compliance review. Amanda, can you briefly outline the two primary types of audits and the specific effects of this announcement?
Amanda:Certainly. There are two primary types of audits for Medicare Advantage. First is Part C Interim Payment Monitoring, which involves targeted oversight of claims and encounter data to monitor payment accuracy in near real time.
The second is the Contract-Level RADV audit, which is retrospective and assesses whether submitted diagnosis codes used to calculate risk scores and payments are adequately supported by clinical documentation. Historically, CMS selected about 60 contracts per year at random and audited a sample of around 35 members per contract.
With the May 21st announcement, CMS is completely revamping this model. CMS is now accelerating RADV audits across seven payment years, 2018 through 2024. And this acceleration is not limited to a select few plans; it applies to the entire Medicare Advantage (MA) industry.
Host: Can you walk us through the scope of the CMS Announcement? What was communicated? And why is it so consequential?
Amanda: At its core, RADV, or Risk Adjustment Data Validation, is how CMS holds Medicare Advantage plans accountable. It’s the audit mechanism CMS uses to verify that the diagnosis codes that plans submit are supported by actual medical records.
That’s always mattered. But what’s different now is scale and urgency. Every plan will be audited, and it’s happening fast.
Depending on the size of the plan, the member sample per contract could now range from 35 to 200.
Additionally, CMS is significantly expanding its internal audit workforce from roughly 40 coders to a projected 2,000. That scale-up signals a shift from limited sampling to near universal oversight.
For health plans, this shift eliminates the past assumption that RADV is a risk faced only by a small subset. That mindset is no longer viable. CMS is moving from random sampling to comprehensive participation.
No more one-year-at-a-time, no more small sample sizes, and no more gamble that “we probably won’t get picked this year.”
Host: In parallel to the audit announcement, CMS issued a memo on May 30th titled “Deadlines for the Submission of Risk Adjustment Data for Risk Adjustment Data Validation Sampling.” What was included in this memo, and why should health plans be paying close attention?
Amanda: This memo is highly relevant because it outlines a series of deadline-driven requirements for closed-period deletes—that is, the removal of diagnosis codes that were previously submitted for past payment years but are no longer valid or supportable.
For context, once a payment year closes, plans can no longer submit new codes for that year, but they can submit deletes to correct inaccurate data. For payment years 2018-2024, the submission windows have closed. CMS is now requiring plans to submit those deletes by a set of firm deadlines ranging from June 16 for Payment Year 2020 to July 15 for Payment Year 2024. After these dates, CMS will temporarily pause acceptance of deletes and corrections, but it will not pause enforcement. Plans are still legally obligated to report and return overpayments. This creates a unique compliance tension: while the data correction window closes, regulatory accountability remains in full effect.
Host: Let’s talk impact. What does this mean for Medicare Advantage plans in practical terms? It seems that some plans may be entering this process underprepared. What are the common vulnerabilities you're seeing?
Amanda: Yes. This news came as a shock. Many plans assumed they would not be selected for contract-level RADV and have not prioritized internal audit readiness. RADV has been viewed as a cost center with limited short-term ROI. So, plans have reduced internal RADV staff over the past few years, shifted focus to V28, whatever the reason, many plans are under-resourced right now. Scaling up mid-year is not always feasible because budgets are set. Teams may not be trained or staffed for this kind of volume, and it takes a qualified staff with years of experience to handle the RADV audit activities. These types of coders are in high demand now. It’s a scramble, you know. CMS is expanding its coders from 40 to 2,000, so plans without this function might face a market shortage.
On top of it all, CMS’s accelerated timelines mean that any diagnosis not submitted as a delete by the deadline could be included in the audit sample, even if the plan had already identified it as erroneous.
Host: Yeah, I can see how this information could incite a sense of haste. What’s at stake if plans do not respond quickly?
Amanda: First, to be clear—plans should not delay. Consequences could be significant like risk of overpayment recoupments, penalties, and reputational damage.
Plans that fail to proactively review and validate past data may find themselves exposed across multiple years of audits. And it’s not just about cleaning up old data. This is forward-looking. CMS is watching how data is reported and how errors are managed in real time. Plans need to treat RADV like a core compliance function, not a nice to have. That means standing up, expanding audit teams, or securing a vendor. Validating multiple years of historical data, and prioritizing the review of conditions CMS and OIG have flagged as high-risk.
Conditions like cancer. Historically, provider documentation habits have led to over-coding, and the way a provider views historical conditions doesn’t always align with how ICD-10-CM guidelines expects coders to interpret them. Plans should focus on the low-hanging fruit, such as items in the OIG toolkit, like strokes in the outpatient setting. This is just a data point. The data setting is a place of service 11. If we see a particular code in a specific place of service setting, we know that 99% of the time, it most likely should not have been captured. Meaning, there’s only a 1% chance that it’s a good code. Let’s just delete all 100%. Plans should be asking, historically, what has been over-coded or miskeyed at a really high rate? Send those in for deletes.
We need to not only assess what’s been coded but also where the data originated, how it was documented, and whether it’s defensible under audit scrutiny.
Host: What do you think is going to be the most difficult part of this for plans?
Amanda: The mindset shift. We tend to think of ROI in terms of growth or new initiatives. But in RADV, the return is in the dollars preserved. Every accurate, properly documented, and defensible diagnosis under audit is a revenue dollar that is protected, not just earned. In today’s environment, protecting existing revenue is just as critical as pursuing new revenue. The cost of inaction, through failed audits or recoupments, can be significant. And with CMS expanding their internal audit team from 40 to 2,000 coders, it’s not theoretical anymore. It’s happening. Plans that invest now in defensibility and audit readiness will be the ones that come out ahead.
Host:Do you have any advice to Medicare Advantage plans listening today?
Amanda: Yes, plans need to know that the expectations have changed. RADV is no longer a sporadic event or something to gamble; it’s a standing operational requirement. The smartest organizations are shifting from a reactive stance to a proactive one, viewing audit integrity not as a cost center but as a revenue protection strategy. Those who act now by investing in compliance, tightening validation, and building out mitigation strategies will be far better positioned in the months and years ahead. If your plan does not know where to start, HealthProof offers risk mitigation and RADV support designed to protect Medicare Advantage plans from audit exposure and revenue loss. We offer support beyond internal coding and with a strong track record with no RADV failures on any codes we've captured - our approach ensures defensible data, audit readiness, and sustainable risk adjustment revenue.
Host: Amanda, this has been incredibly helpful. For anyone listening, if there’s one takeaway, it’s this mindset shift of protecting revenue. Thanks so much for your time today.
Amanda: Thanks for having me. And good luck to all the MA plans; it’s a scramble right now, but it’s a much-needed shift to protect the integrity of healthcare in the U.S.
Host: Thanks for listening to this bonus episode of Current Trends for Payers podcast. Get audit ready insights at usthealthproof.com.
