What Medicare Advantage Plans Should Know About RADV Audits

If you work anywhere near a Medicare Advantage plan right now, you've probably noticed the conversation getting louder. Federal oversight is picking up speed, and the way CMS reviews payments to health plans is changing fast. Plans that were used to occasional reviews are now facing something much more continuous.

So let's break this down in plain language. What are these reviews, why is everyone talking about them, and what should plans actually be doing about it?

What These Reviews Actually Are

In simple terms, this is how CMS double checks the money it pays out to health plans.

Here's how it works. Medicare Advantage plans get paid based on how sick their members are. The sicker the population, the higher the payment, because those members cost more to care for. Plans report this through diagnosis codes. CMS then comes back and asks, "Okay, prove it. Show us the medical records that back up those diagnoses."

That review process is called Risk Adjustment Data Validation. It exists because federal estimates suggest health plans may be submitting around seventeen billion dollars worth of diagnoses each year that aren't fully supported by documentation. That's a lot of money, and CMS wants it back when the records don't add up.

Why This Matters More Right Now

Things have shifted in a big way over the past year.

The Acceleration Of Federal Oversight

Back in May 2025, CMS announced it was speeding everything up. Instead of auditing roughly sixty plans a year, the agency now plans to review every eligible contract annually. That's around five hundred and fifty plans. New reviews are being kicked off roughly every three months, and Payment Year 2020 is already underway as of February 2026. If you want a deep dive into the January 2026 update and what changed operationally, this breakdown on RADV audits medicare advantage walks through it clearly.

The Financial Stakes

Even after a September 2025 court decision pulled back parts of the 2023 Final Rule, the financial risk hasn't gone away. Sample sizes can range from thirty five to two hundred enrollees per contract depending on size. If the records don't support the diagnoses, CMS collects the overpayment. Historical reviews found error rates between five and eight percent, which gives you a rough sense of the exposure.

The point is, this isn't a small operational task anymore. It's a financial event.

How The Review Process Works

There are four basic phases, and understanding them helps demystify the whole thing.

Notification And Preparation

It starts with a notice through the Health Plan Management System. The plan downloads its enrollee data, pulls together a response team, and starts mapping out timelines.

Chart Retrieval

Next comes the heavy lifting. Plans build chase lists, reach out to providers, and gather medical records. CMS restored the five month submission window in January 2026, giving plans a bit more breathing room than the shorter window announced earlier.

Chart Review And Validation

Certified coders go through every record and check it against the MEAT criteria. MEAT stands for Monitored, Evaluated, Addressed, and Treated. If a diagnosis can't pass that test based on the documentation, it doesn't count. Plans can submit up to two records per audited condition, but only one valid record is needed to support payment.

Submission And Rebuttal

Once everything is reviewed, records are formatted to CMS specifications and submitted. Plans then have a chance to rebut findings before final determinations land.

What Gets A Plan Selected

A few years ago, you could reasonably ask whether your plan would be reviewed this year. That question is mostly gone now.

CMS still looks at factors like coding anomalies, unusual risk scores, and known compliance issues when prioritizing. But under the expanded program, every eligible contract is on the list. So the real question isn't whether your plan gets reviewed. It's when, and whether you'll be ready when the notice arrives.

This is a mindset shift more than anything else. The work moves from periodic preparation to ongoing readiness.

Documentation Standards That Make Or Break The Outcome

This is the part most coders and compliance teams already know, but it's worth restating because the details are where plans win or lose.

What Records Need To Show

Every diagnosis tied to a payment needs a real, face to face encounter behind it. The record has to show the provider's credentials, a clear signature, a date of service that falls within the audited year, and actual clinical evidence that the condition was being managed. These documentation expectations sit alongside other medical billing compliance requirements that healthcare organizations juggle every day.

The Mistakes That Keep Showing Up

The same problems come up over and over. Missing signatures. Chronic conditions that aren't fully documented. Old conditions coded as if they're still active. Diagnoses floating around without a clear link to an encounter. None of these are exotic mistakes. They're everyday documentation gaps that turn into unsupported findings.

How Plans Can Stay Ready

You can't really cram for this kind of review. The plans that handle it well treat readiness as an everyday discipline.

Practical Steps

Start by running your own chart audits using CMS criteria before CMS does. You'll find the same gaps the reviewers would find, and you'll have time to fix them.

Build stronger provider relationships now, before the requests pile up. When multiple plans are pulling records at the same time, provider offices get overwhelmed fast.

Train coding teams on defensibility, not just accuracy. There's a difference between a diagnosis that's technically right and one that can survive a documentation review.

Where Technology Fits

Manual processes don't really scale when reviews are happening every quarter across an entire book of business. Tools that flag documentation risks, manage chart retrieval workflows, and connect to provider portals are becoming the norm rather than a nice to have.

Wrapping Up

The direction is clear. Federal reviews of Medicare Advantage payments are faster, broader, and continuous. The plans that handle this well aren't the ones with the biggest compliance budgets. They're the ones that built documentation quality into the everyday workflow, so when a notice arrives, it's just another Tuesday.

If your plan is still thinking about audit readiness as a once a year project, this is a good moment to rethink that.

Frequently Asked Questions

What is the goal of this kind of review? The goal is to confirm that diagnoses submitted by a health plan are backed by real medical records, so CMS payments reflect actual member health status rather than coding alone.

How often do these reviews happen now? CMS now plans to review every eligible contract every year, with new reviews kicked off roughly every three months.

How long do plans have to submit medical records? CMS restored the five month medical record submission window in its January 2026 update, giving plans more time to retrieve records from providers.

What documentation standard do reviewers use? The MEAT criteria remain the benchmark. A diagnosis needs to be Monitored, Evaluated, Addressed, or Treated, with clear documentation from a face to face encounter.