The RADV Scramble Is Here: What Every Medicare Advantage Plan Needs to Do Right Now
- Francisco Izquierdo
- Jun 2
- 8 min read
A Revenue Integrity Series I Paper No. 2
If your Medicare Advantage plan has not yet begun preparing for a Risk Adjustment Data Validation (RADV) audit, the clock is no longer just ticking - it is running. CMS has fundamentally transformed its audit program, and 2025 and 2026 represent the most consequential compliance period in the history of Medicare Advantage risk adjustment.
This is not a drill. It is not a warning of something that might happen. It is already underway.
Why the Urgency Is Real
For years, RADV audits were a manageable risk. CMS audited approximately 60 Medicare Advantage contracts per year, reviewing roughly 35 records per plan. Most plans were never touched. That era is over.
In May 2025, CMS announced a sweeping transformation of the RADV program. The scale of what is now in motion is unprecedented:
CMS expanded its audit scope from approximately 60 MA plans per year to all eligible MA plans - approximately 550 contracts - annually.
The number of records reviewed per plan increased from a standard 35 to between 35 and 200 records per plan per year, based on plan size.
CMS expanded its medical coding workforce from 40 to approximately 2,000 coders by September 1, 2025, giving the agency the human firepower to match its ambition.
CMS has announced plans to deploy artificial intelligence as a support tool for medical coders during RADV audits, helping flag potential documentation issues more efficiently than traditional manual review.
The financial stakes are unambiguous: CMS attributes approximately $17 billion in annual MA overpayments to unsupported diagnoses - the core driver behind its enforcement push - and projects recovering $4.7 billion through extrapolation alone between 2023 and 2032. This is not a compliance footnote. It is the single largest program integrity initiative in Medicare Advantage history.
The audit backlog is already being worked through at full speed. CMS expects Payment Year 2020 RADV audits to have begun as early as February 2026, following its broader effort announced in May 2025 to speed completion of audits for payment years 2018 through 2024. Every payment year from 2018 forward is on the table.
CMS published its formal RADV Audit Schedule on March 4, 2026, giving plans a structured look at what is coming; however, the cadence leaves little room for deliberation. Future payment year audits are being initiated approximately every three months. Plans that are not ready when their audit window opens will simply not be ready.
What Makes This Particularly Dangerous
The capacity crunch is real. If every MA plan is trying to retrieve medical records simultaneously, there may not be enough chart retrieval vendors to go around. Providers, already stretched thin, may experience fatigue from a sudden flood of record requests, leading to slower turnaround times or reduced responsiveness. Plans that wait to mobilize their chart retrieval strategy will find themselves competing for limited vendor capacity against hundreds of other plans doing the same thing at the same time.
The documentation standard is unforgiving. Minor errors such as missing provider signatures, vague clinical language, or unsupported diagnoses can lead to disallowed codes and repayment demands. Every diagnosis that contributes to a member's risk score must be supported by a face-to-face encounter, documented with clinical specificity, during the payment year under audit.
The financial exposure is compounding. For audited contracts where unsupported diagnoses are identified, CMS collects overpayments. Prior audits from payment years 2011 through 2013 found 5-8% error rates—a benchmark that, when applied through extrapolation across a full contract population, translates into significant recoupment demands. While portions of the 2023 RADV Final Rule's extrapolation provisions were vacated by a federal court in September 2025, CMS appealed the decision and has emphasized that RADV audits will continue moving forward. The financial exposure, with or without extrapolation, is material.
Seven years of data, compressed into one window. 2025 and 2026 are especially acute, as seven years of data responses must be shared with CMS within a very tight window. No plan should assume it has more time than the audit calendar shows.
Insider Tip No.1: Know Your Audit Status and Act on the Published Schedule
The first step is simply knowing where you stand. CMS has published its RADV Audit Schedule and consolidated FAQs as of March 4, 2026, and plans should be monitoring CMS's RADV webpages closely. If your contract has been notified of an audit initiation, the five-month medical record submission window—which CMS restored following stakeholder feedback—is your operational runway. Use every day of it.
If you have not yet received an audit initiation notice, use this time to conduct a mock audit against your highest-risk payment years. Identify your most vulnerable HCC codes, pull a sample of supporting records, and assess them against CMS documentation standards before CMS does it for you.
Insider Tip No. 2: Prioritize Chart Retrieval Before the Market Is Saturated
With all 550 eligible MA plans now subject to annual audits, the medical records retrieval market is under extraordinary strain. Plans that treat chart retrieval as a reactive, audit-triggered activity will find themselves at the back of a very long line.
The solution is to establish standing chart retrieval relationships with your highest-volume provider groups now, before an audit notice arrives. This means:
Identifying the provider sites most likely to hold records for your highest-risk members
Establishing retrieval agreements and workflows in advance
Prioritizing electronic retrieval wherever possible to reduce turnaround time
Conducting routine rospective chart pulls as part of your ongoing risk adjustment program - not as an emergency response to an audit notice
Plans with established retrieval infrastructure will move faster, submit more complete records, and present more defensible documentation when it matters most.
Insider Tip No. 3: Invest in Pre-Audit Clinical Validation
The single most effective thing a plan can do before a RADV audit is conduct rigorous internal clinical validation of the diagnosis codes most likely to be scrutinized. This means having certified, clinically credentialed risk adjustment coders - not just administrative reviewers - examine the medical record documentation supporting each HCC code in your risk adjustment submission.
The key questions for each audited diagnosis:
Is the condition documented as present, assessed, and addressed during a face-to-face encounter in the payment year?
Does the documentation reflect clinical specificity consistent with the submitted HCC?
Is the provider’s signature present and legible?
Is the documentation free of copy-forward or cloned note risk?
Conditions that do not pass this internal review should not be submitted - or should be accompanied by supplemental documentation that strengthens the record. Submitting unsupported codes is not just a compliance risk; in the current enforcement environment, it is a financial one.
Insider Tip No. 4: Prepare Your Dispute and Appeal Strategy in Advance
RADV audits are not final the moment CMS issues its findings. Plans have the right to dispute audit results and pursue reconsideration. CMS has published formal MA RADV Audit Dispute and Appeal Guidance for the Level 1 Reconsideration process, and plans should be familiar with this process before they receive audit results - not after.
A prepared dispute strategy includes:
Knowing which HCC codes have the strongest supplemental documentation available
Having a process to quickly retrieve additional clinical evidence when a code is challenged
Understanding the reconsideration timeline and submission requirements
Engaging clinical and legal expertise to evaluate the strength of each disputed finding
Plans that treat the dispute process as an afterthought will leave recoverable findings on the table.
Insider Tip No. 5: Treat RADV Readiness as a Continuous Program, not a One-Time Event.
RADV audits are no longer episodic events. They are now a routine, high-stakes compliance reality for Medicare Advantage organizations. With annual audits covering every eligible contract, a plan that achieves RADV readiness for one payment year must sustain it for the next.
This means building readiness into your standard operating model:
Prospective & retrospective chart review on an ongoing cycle - not just triggered by audit notices
Provider education focused on documentation specificity and compliance with CMS face-to-face encounter requirements
HCC validation workflows embedded into your coding operations year-round
Audit simulation exercises conducted annually against your most recent payment year submission
Analytics to identify statistically anomalous coding patterns before CMS does - because CMS is now using AI-assisted tools to flag exactly those patterns
How Alcyon and Ascend Can Help
RADV audits at this scale demand more than internal effort alone. They require clinical depth, operational capacity, specialized audit expertise, and—critically—the excess capacity that most plans simply do not have in-house when audit volume spikes across the entire industry simultaneously.
Alcyon Consultants brings the strategic and operational leadership to help plans assess their current RADV exposure, design and execute a readiness program, and navigate the dispute and appeal process with the rigor that high-stakes audit findings require. Our team has built compliance programs, conducted mock RADV audits, and guided plans through CMS enforcement actions at some of the most complex Medicare Advantage organizations in the country.
Ascend Revenue Integrity delivers the clinical execution capacity that plans need when the audit window opens. Ascend's team of certified risk adjustment coders—who are also foreign medical graduates and/or registered nurses—provides the clinical validation depth that distinguishes defensible documentation from documentation that merely exists. Ascend's proprietary Ascend Engine supports chart retrieval, coding workflows, and audit preparation under a compliance framework purpose-built for RADV and CMS scrutiny. Health plans and providers working with Ascend consistently achieve 10:1 returns on their investment.
Together, Alcyon and Ascend offer:
Mock RADV audit preparation and gap assessment
Pre-submission clinical validation of HCC codes
Chart retrieval support and coordination
Prospective and retrospective chart review and HCC coding
Audit dispute and Level 1 Reconsideration support
Provider education and documentation improvement programs
Advanced analytics to identify coding risk before CMS does
Operational capacity to handle audit volume surges without disrupting your core business
The RADV scramble is not coming; it is here. The plans that will navigate it successfully are the ones that are building their response infrastructure now—with the right partners, the right clinical expertise, and a strategy that goes beyond pulling charts and hoping for the best.
The Bottom Line
Every Medicare Advantage plan is now an audit target. The question is not whether CMS will come - it is whether your plan will be ready when it does. The combination of a compressed timeline, simultaneous industry-wide demand for chart retrieval resources, and an enforcement posture that CMS has described in its own words as "aggressive" leaves no room for a reactive approach.
Start now. Build the infrastructure. Get the right partners in place. And submit with confidence.
The Road Ahead
This is the second in a series of thought leadership papers Alcyon and Ascend are publishing together. Future topics will include the impact of claims linkage for MA supplemental submissions starting in calendar year 2027, COB and ESRD revenue recovery strategies, value-based provider engagement models for risk and quality, and the evolving landscape of CMS V28 compliance for MA plans.
Our shared conviction is straightforward: every legitimate dollar a health plan is owed should be captured, defended, and retained. Revenue integrity is not a back-office function. It is a strategic imperative - one that demands clinical expertise, operational discipline, compliance rigor, and the right partners. We invite health plan executives, CFOs, CMOs, and VP-level operations leaders to reach out and start the conversation.
Alcyon Consultants partners with Ascend Revenue Integrity to deliver full-spectrum revenue integrity solutions for Medicare Advantage and ACA health plans, combining deep operational consulting expertise with industry-leading clinical coding, risk adjustment, and premium reconciliation capabilities. Reach out to learn how we can support your plan's RADV readiness strategy.
Alcyon Consultants, LLC Precision. Integrity. Momentum. (305) 815-2851I
Ascend Revenue Integrity Elevating Accuracy. Strengthening Compliance. Maximizing Revenue. www.ascendrevenueintegrity.com I Miami, Florida
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