Medicare Advantage organizations are entering a transformative era of compliance oversight, with the Centers for Medicare & Medicaid Services (CMS) sharpening its focus on payment accuracy.
Recent regulatory updates have placed unprecedented attention on how diagnoses translate into risk-adjusted payments across the program.
For Medicare Advantage organizations seeking detailed operational insights, a thorough overview of the RADV audit in risk adjustment framework is essential to navigate the accelerated audit environment of 2026.
CMS issued a key memorandum on January 27, 2026, restoring the five-month medical record submission window and confirming that Payment Year 2020 audits are now underway.
What Is a RADV Audit?
A Risk Adjustment Data Validation (RADV) audit is the official process the Centers for Medicare & Medicaid Services uses to verify that diagnosis codes submitted by Medicare Advantage plans are supported by enrollees' medical records.
The Medicare Advantage RADV program is CMS's primary tool to address overpayments to Medicare Advantage Organizations (MAOs).
Purpose of the RADV Program
The fundamental goal of a RADV audit is to ensure that MA plans receive payments that accurately reflect the documented disease burden of their members.
If diagnoses are unsupported by medical records, CMS may collect overpayments from audited contracts.
This validation process protects both the Medicare Trust Fund and beneficiaries by safeguarding federal taxpayer dollars.
CMS describes the program as essential to its strategic pillar of being a responsible steward of public funds.
Who Conducts RADV Audits
CMS, through its Center for Program Integrity and the Audits and Vulnerabilities Group, initiates and oversees every Medicare Advantage RADV audit.
Audit notices are transmitted through the Health Plan Management System, and all inquiries are directed to [email protected].
The Connection Between RADV Audits and Risk Adjustment
Risk adjustment lies at the heart of how Medicare Advantage plans receive funding from CMS. Without accurate validation, the entire payment model becomes vulnerable to inflated risk scores and improper expenditures.
How Risk-Adjusted Payments Work
Medicare Advantage plans receive risk-adjusted payments based on the diagnoses they submit for enrollees, with higher payments tied to patients carrying more serious or chronic conditions.
CMS verifies these claims through RADV audits to confirm that diagnoses used for payment are actually supported in the medical record.
The Financial Stakes Involved
Federal estimates suggest Medicare Advantage plans may overbill the government by approximately 17 billion dollars annually, while the Medicare Payment Advisory Commission (MedPAC) places that figure as high as 43 billion dollars per year.
Completed CMS audits for Payment Years 2011 through 2013 found error rates between five percent and eight percent of payments.
Key CMS Updates Driving the 2026 Audit Landscape
The May 2025 CMS announcement and the follow-up January 2026 memorandum reshaped expectations for every Medicare Advantage organization.
Together, these updates establish a faster, broader, and more predictable audit cadence than the industry has ever experienced.
Expanded Audit Volume and Sample Sizes
CMS will increase its audit reach from roughly 60 MA plans per year to all eligible MA plans annually, which represents approximately 550 contracts.
Sample sizes will also expand from a flat 35 records per plan to a variable range of 35 to 200 records, calibrated to the size of the contract under review.
Restored Five-Month Submission Window
In response to stakeholder feedback, CMS restored the five-month medical record submission window after initially proposing a three-month timeline in May 2025.
For Payment Year 2019 audits initiated in June 2025, deadlines were extended into November 2025 to give MA plans a realistic time to retrieve records.
Quarterly Audit Initiation Cadence
CMS confirmed that Payment Year 2020 audits began in February 2026 and that future audits will initiate approximately every three months.
The agency has also published a formal audit schedule covering Payment Years 2020 through 2025 on its RADV Documents and Data page.
The RADV Audit Process Explained
Understanding the audit lifecycle helps Medicare Advantage organizations prepare more effectively for what lies ahead.
The process is structured, deadline-driven, and built around documentation defensibility from start to finish.
Sample Selection and Notification
CMS selects contracts based on multiple factors, including coding anomalies, outlier risk scores, and known compliance concerns.
Once selected, the plan receives an audit notice via the Health Plan Management System and downloads the Enrollee Data List from CMS's CDAT portal.
For Payment Year 2020 audits, CMS will focus on enrollees ranked in the top quartile of program-wide RADV-eligible members by risk score concentration.
This represents a broader pool than the top decile used in Payment Year 2018 and 2019 audits, increasing the universe of records subject to scrutiny.
Documentation Standards Under MEAT
Every diagnosis code submitted for risk adjustment must satisfy the MEAT criteria, meaning the condition must be Monitored, Evaluated, Addressed, or Treated during a documented patient encounter.
Records must include a valid face-to-face encounter, legible provider credentials and signature, and a service date that aligns with the payment year under audit.
CMS allows a maximum of two medical records per audited Hierarchical Condition Category (HCC), though only one valid record is required to support payment.
This rule reinforces the emphasis on documentation quality rather than volume of submitted records.
How MA Plans Can Prepare for RADV Audits
Given the accelerated pace and increased scrutiny, Medicare Advantage organizations should treat audit readiness as an ongoing operational discipline.
Reactive responses are no longer viable in a program that audits every eligible contract annually.
Strengthening Documentation Practices
Internal chart audits using CMS criteria allow plans to identify gaps before CMS does, reducing the chance of unsupported diagnoses entering the audit sample.
Provider education is equally critical, since simultaneous record requests across multiple MA plans can quickly overwhelm provider offices and delay retrieval.
Leveraging Technology and AI
CMS has confirmed plans to deploy artificial intelligence as a support tool for medical coders during RADV reviews, although final coding decisions will continue to be made by certified human coders.
MA organizations should evaluate AI-powered validation platforms, workflow management tools, and dashboards that provide leadership visibility into emerging audit risk.
Conclusion
The 2026 RADV audit environment represents a permanent shift in how Medicare Advantage plans must manage compliance, documentation, and financial exposure.
CMS has made clear that strengthening oversight of MA payments is a top program integrity priority that will continue regardless of ongoing litigation around the 2023 Final Rule.
For Medicare Advantage organizations, the strategic imperative is to build year-round audit readiness rather than treating each notice as a one-time event.
Plans that invest in strong documentation, provider partnerships, and AI-enabled validation now will be best positioned to defend their risk-adjusted payments when the next RADV notice arrives from CMS.
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