With the January 27, 2026 announcement from The Centers for Medicare & Medicaid Services (CMS)1 regarding the Risk Adjustment Data Validation (RADV) program, it is clear that CMS intends to honor their commitment to strengthen oversight of Medicare Advantage (MA) payments, accelerate and expand the use of RADV audits, and utilize artificial intelligence to streamline human coding reviews. Are your teams prepared to respond to the RADV audit notice within the required five-month window, while balancing your other risk adjustment programs?
While the memo acknowledges the District Court ruling in the Humana v. Becerra case—which vacated portions of CMS’s 2023 RADV Final Rule, including the use of extrapolation—HHS has appealed the decision. This leaves room for Medicare RADV to flare up in the future. That said, CMS will fully comply with the order while it is in effect.
With the announcement from CMS comes additional clarification on how they plan to roll out additional RADVs, reduce burden on plans and providers, balance the volume of medical record submissions needing review, and leverage technology to further accelerate the review process.
During an RADV audit, CMS selects a sample of enrollees and requests corresponding medical records from the MA plan. These records are reviewed to confirm that the documented diagnoses meet CMS requirements. If unsupported diagnoses are found, CMS may recalculate payments and recover overpayments from the health plan. This audit process maintains program integrity and ensures accurate payments.
While RADV audits have historically been uncertain with long delays, continued RADV regulations and accelerated timelines warrant immediate attention. Have you thought about how you will strategize and prioritize chart submission? How will you determine which charts are likely to result in a favorable outcome?
Health plans can be prepared by focusing on accurate documentation, proactive internal audits, delete/risk mitigation audits, and—when necessary—leveraging a strong RADV partner to assist in review and prioritization of submissions. Wakely assists plans with their RADV initiatives and developing robust RADV playbooks.
Reach out to Debbie Conboy to learn more.
Operational Considerations
- Provider communications
- Medical record target lists
- Medical record retrieval
- Medical record review
- IRR / second pass
- Medical record selection for submission
- Submission
- Reporting and tracking
- Financial projections related to findings
More Resources:
Learn more about Wakely’s expertise in Medicare Advantage
Learn more about Wakely’s work with Risk Adjustment
