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CMS RADV Audit Expansion Signals Urgent Need for Plan Readiness


CMS has just announced a major expansion of its audit program for Medicare Advantage (MA) plans—shifting from sampling a few contracts to auditing all eligible plans each year.


The Trump Administration aims to complete all outstanding RADV audits for PY 2018–2024 by early 2026. This move brings unprecedented scrutiny, larger record volumes, and significant extrapolation risk.


At Rebellis Group, we’re already helping plans prepare for this new era of oversight—and we’re ready to support you.


What’s New:

  • Broader Audit Reach: CMS will now audit every eligible plan annually, up from the previous average of 60.

  • More Records Reviewed: Plans may now face 35–200 records per audit, depending on enrollment size.

  • Rapid Workforce Scale-Up: CMS is growing its medical coding team from 40 to 2,000 to verify flagged diagnoses manually.

  • Technology-Driven Reviews: New tools will scan medical records to flag unsupported risk-adjusted conditions.

  • Recovery of Past Overpayments: In partnership with HHS-OIG, CMS plans to recoup unpaid audit findings from prior years.

 

What This Means for Plans:


CMS is raising the bar—and the risk. Plans must now treat audits as an expected, annual reality rather than a rare occurrence. This creates both operational pressure and financial exposure if documentation, coding, or compliance gaps exist.


How Rebellis Group Can Help:


We’re actively supporting Medicare Advantage plans in preparing for this expanded audit environment through:


  • Retrospective Audit Support – We conduct comprehensive mock audits to identify vulnerable diagnoses before CMS does.

  • Clinical Documentation Reviews – Our team ensures that HCCs are fully supported with complete and compliant medical records.

  • Extrapolation Risk Modeling – We help quantify financial exposure from potential audit findings and advise on mitigation strategies.

  • Coding & Compliance Training – We equip your teams with the latest guidance and practical strategies to close risk gaps.

  • Ongoing Compliance Monitoring – We design and implement internal controls aligned with CMS’s evolving audit criteria.

  • Interim staffing support - We offer experienced, certified coders to supplement your internal team during the expanded RADV audits. Our staff can assist with chart reviews, documentation validation, and audit preparation—helping you meet the aggressive CMS deadlines, reduce compliance risk, and manage workload without overextending your internal team.

 

The Bottom Line:

CMS is scaling aggressively. Now is the time to reinforce your compliance foundation—and we’re here to guide you every step of the way.


Let’s talk about how Rebellis Group can help your plan prepare and protect against audit risk.




 
 
 

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