Continuing its efforts to reduce fraud, waste, and abuse in Medicare, the Centers for Medicare & Medicaid Services (CMS) has announced plans to significantly enhance Risk Adjustment Data Validation (RADV) auditing in Medicare Advantage. Beginning immediately, CMS will audit all eligible Medicare Advantage contracts for each payment year going forward.
CMS intends to expand the audits in two ways: (1) by increasing the size of each contract sample from 35 enrollees to between 35 and 200 enrollees, depending on the size of the contract; and (2) by moving from auditing approximately 60 contracts per year to auditing all contracts every year.
Additionally, CMS announced it plans to complete all RADV audits for payment years 2019 through 2024 by early 2026. CMS will use “enhanced technology,” such as artificial intelligence, to review medical records and flag unsupported diagnoses. It also plans to increase the number of medical coders from 40 to approximately 2,000 to review flagged diagnoses.
Implications for Practices
Because the number of RADV audits will increase significantly, medical record requests from Medicare Advantage organizations will also increase significantly. Providers will increasingly be expected to produce medical records that substantiate the relevant diagnosis and that have been signed by an appropriate provider, including the provider’s credentials.
Clinicians may also be expected to complete attestations when an acceptable medical record is not identified. Some providers may be asked to produce medical records for large numbers of patients if they contract with multiple Medicare Advantage organizations or if the same contract is selected for audit in multiple years.
When medical records are requested, it is the responsibility of the billing provider to submit the requested documentation. A lack of proper or complete documentation can invalidate the services reported, potentially resulting in claim denials or overpayment issues.
Documentation
Certain oncology diagnosis codes are deemed “high risk” for miscoding and are more likely to be flagged in audits, because the error rates related to their use are high. The oncology diagnosis code selected must accurately reflect an active cancer diagnosis or a history of cancer as appropriate. CMS’ Calendar Year 2023 Medicare Part C Cancer Supporting Documentation Reference and ASCO’s August 2024 Coding Tip of the Month include specific criteria for coding a history of cancer diagnosis.
Additionally, sufficient documentation in provider records “must verify that services performed were compliant with CMS policies and required the level of care billed,” according to CMS’ recently updated fact sheet, “Complying With Medical Record Documentation.” In fact, CMS found that insufficient documentation was the cause of 59.8% of all improper Medicare payments in 2024.
Documentation 2024 insufficiencies, particularly for office visits, may result from errors such as the documentation not supporting the reported level of service, failure to meet the signature requirements for payment, or inadequate documentation for the billed date of service.
A diagnosis identified in one payment year must be confirmed by a medical record indicating a date of service in the prior year only. A single medical record and associated date of service cannot substantiate a diagnosis across multiple years.
Why Audit Medicare Advantage Plans?
Medicare Advantage plans receive risk-adjusted payments based on the diagnoses of the enrollees covered by the plans. When enrollees have more serious or chronic conditions, Medicare Advantage plans receive higher payments from Medicare to offer Medicare Advantage plans. To verify the accuracy of these claims and the diagnoses of enrollees, CMS conducts RADV audits to confirm that diagnoses used for payment are supported by medical records. If the agency finds that the diagnoses are incorrect, it collects overpayments from the Medicare Advantage plans for inaccurate diagnoses.
© American Society of Clinical Oncology. ASCO in Action. July 1, 2025. All rights reserved.
