CMS Kicks Off PY2019 RADV Audits: What Medicare Advantage Organizations Must Know Now

On Friday, June 13th, CMS officially initiated PY2019 Medicare Advantage RADV audits, marking a significant escalation in oversight and enforcement for Medicare Advantage Organizations.  Notifications were issued to the first wave of selected contracts through the Health Plan Management System (HPMS), launching a highly scrutinized audit process. The focus of these audits is to validate that all diagnoses submitted for risk-adjusted payment are fully supported by medical record documentation from face-to-face encounters that occurred between January 1 and December 31, 2018.

Here’s what we know—and what health plans must act on immediately.

Key Takeaways from the PY2019 RADV Audit Launch

• First Wave of Contracts: CMS has identified 45 MA contracts as part of the first batch of PY2019 audits. This wording implies additional batches are likely forthcoming.

• Shortened Timeline: MAOs previously had up to 22 weeks to submit documentation during audits. That window is now reduced to 12 weeks, increasing the urgency and complexity of audit readiness.

• Record Submission Limits: MAOs are now limited to 2 medical records per HCC, a significant reduction from the previous 5-record allowance—significantly limiting the ability to defend a diagnosis.

• Sampling Methodology:  CMS is using random sampling from within the top decile of contracts identified by improper payment prediction models—indicating that these audits are highly targeted toward contracts with elevated risk of overpayment.

• Impact of Retrospective Deletions: If a diagnosis was retrospectively deleted before the final overpayment calculation, and the HCC was subsequently removed from payment, CMS may grant an administrative exception—but only if valid documentation is submitted for the sampled HCC.

 What This Means for MAOs

The operational and strategic implications of these audits cannot be overstated.

• Audit timelines have compressed.

• Documentation limits have narrowed.

• Sampling is now predictive and risk-based.

The stakes are higher—and MAOs must be prepared.

 How Rebellis Can Help

As a trusted consulting partner in risk adjustment and compliance, we are here to support. 

If your organization was selected for the first round of PY2019 audits, we can assist immediately with:

• Medical record abstraction

• RADV project management

• Appeals preparation

• Extrapolation risk analytics

If your organization wasn’t selected this time, consider it a window of opportunity—additional audit waves are expected, and now is the time to strengthen operational readiness and proactively prepare. In addition to the above, Rebellis can provide:

• Development of RADV audit playbooks

• Organizational RADV audit readiness assessment

• Overpayment exposure analysis

• Mock RADV audits to pre-identify high-risk HCCs

• Code deletion analytics using OIG toolkit methodologies

NEW RADV WEBINAR - In this timely webinar—From Compliance to Cost: Navigating the Impact of RADV Audits—we’ll unpack what plans need to know now and how to prepare for what’s next. We’ll also be joined by Jeannine Bumford, Director of Risk Adjustment at CHRISTUS Health Plan, who will share real-world insights into the current challenges plans are facing and how they’re balancing immediate audit demands with long-term strategy. Join us on Thursday, June 26 from 1–2 PM ET.

REGISTER NOW

Get Ahead of CMS RADV Audit Risk

If your organization is facing a PY2019 audit or preparing for future rounds, let’s connect to ensure your organization is equipped with the strategy, analytical data, and resources to support accurate and compliant risk-adjusted payments. Connect with Rebellis Group today to discuss how we can support your risk adjustment strategy and compliance readiness.