The Centers for Medicare & Medicaid Services (CMS) on Tuesday issued a memo outlining adjustments to its previously announced plans to accelerate Risk Adjustment Data Validation (RADV) audits for all eligible Medicare Advantage contracts.
In a memo to Medicare Advantage organizations on Tuesday, Steven Ferraina, acting director, Audits and Vulnerabilities Group, Center for Program Integrity, said the agency has made changes to the RADV audit strategy following stakeholder concerns about operational burden, timing, and transparency.
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In May 2025, CMS announced an aggressive strategy to catch up and accelerate the audits. The agency intended to hire 2,000 coders to complete all audits for payment years 2018 through 2024. Under the strategy, CMS announced it would shorten the medical record submission window from five months to three months; implement variable sample sizes (35 to 200 enrollees per contract); reduce allowed medical records per audited HCC from five to two; and incorporate new artificial intelligence (AI)-enabled coding support technology in the process.
In response to industry concerns, the agency met with stakeholders throughout the summer of 2025 and decided to make the following changes to its audit strategy.
Restore the five-month medical record submission window: CMS will go back to the five-month submission window to give organizations additional time to obtain medical records from providers. It has also extended the hardship exception request for payment year 2019 RADV audits.
Schedule new quarterly audit cycles: To reduce audit overlap and provider burden, CMS will initiate new audits approximately every three months. The agency expects to start payment year 2020 audits by February 2026.
Clarify the use of variable sample sizes: CMS will use statistically valid samples of 35 to 200 enrollees beginning with payment year 2020 audits. Ferraina said it’s unlikely that smaller contracts will be assigned the largest sample size.
Specify medical record requirements: CMS confirmed that it will require a maximum of two medical records per audited HCC for future audits but only one valid record is needed to support payment. “This approach strikes an appropriate balance of accelerating the completion of RADV audits while keeping MA organizations and provider burden manageable,” Ferraina said.
Use of AI‑supported coding tools: CMS will move forward with new technology that assists coders but noted that all overpayment‑related decisions will remain with certified human coders. Technology will be fully evaluated prior to introduction in RADV audits.
Redesign RADV program webpages: CMS said it will launch newly designed webpages to better organize audit program documents, such as the upcoming audit calendar, guidance documents, frequently asked questions, audit methods, and instructions.
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Response to legal developments: The Department of Health and Human Services has appealed a federal court decision in September 2025 that vacated CMS’ 2023 RADV Final Rule but CMS said the agency will fully comply with the court order as long as it remains in effect, while pursuing upcoming RADV payment year audits.
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