On May 21, 2025, Centers for Medicare & Medicaid Services (CMS) announced it will immediately expand its audits of Medicare Advantage (MA) plans to verify that the MA plans only submit accurate diagnoses for its enrollees. Since MA plans receive risk-adjusted payments based on the submitted diagnoses, CMS uses these Risk Adjustment Data Validation (RADV) audits to address improper overpayments by confirming that the submitted diagnoses are supported in the enrollee’s medical record. Although CMS directs these audits toward the MA plans, they inevitably impact providers. Therefore, providers should keep in mind the following:
- These audits lead MA plans to increase requests to providers for medical records.
- CMS is still performing RADV audits dating back to 2018, presenting a high probability of significant overpayment identification and recovery efforts.
- Most critically, MA plans can, and often do, downstream any CMS overpayment recoveries and penalties to the providers.
Therefore, it is critical that providers remain vigilant in documenting all patient diagnoses accurately.
Should you have any questions regarding the above, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
