Those working in the risk adjustment arena realize that there are two common Risk Adjustment Data Validation (RADV) audits: one that tells Congress an error rate, and one that takes money back from risk adjustment payers.
These latter audits come in two flavors: one for Medicare Advantage (MA) payers called the Centers for Medicare & Medicaid Services (CMS) RADV, and one for Patient Protection and Affordable Care Act (PPACA) payers known as the U.S. Department of Health and Human Services (HHS) RADV. Both ensure that the data submitted by the payers is accurate and truly represents the patient’s condition.
HHS RADV audits are generally about a year behind; CMS RADV audits have been more than five years behind. This year they finished auditing payment year 2018, which includes services in 2017. By my calculations, that’s seven years, and way too late!
When Dr. Mehmet Oz was appointed as CMS Administrator in April 2025, he made a bold move to tighten the timeframe for the CMS RADV audits. CMS announced that it would augment its current staff of 40 coders by hiring 2,000 more coders by Sept. 1, 2025. These 2,000+ auditors would allow CMS to increase the number of records audited from 35 records per health plan per year to between 35 and 200 records per health plan per year, based on the size of the health plan. Furthermore, it would not just audit a sample of 60 MA contractors, but all of them, to thwart the hemorrhaging of overpayments from payment years 2018-2024. These are the years that allow CMS to extrapolate findings, which could mean billions of clawbacks from payers. This ambitious initiative set a goal of completing these audits by the end of 2026.
“We are committed to crushing fraud, waste and abuse across all federal healthcare programs,” Oz said in a statement. “While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”
However, a Bloomberg report published earlier this month indicates that there have been no hires, no postings, and no updates, according to Ryan Peterson, an advisor to health plans. An article from Ainvest implies that the Administration’s hiring freeze may be contributing to the delay, also noting that no new job postings have been listed on the USAJobs.gov website.
If CMS gets its act together on this push to conduct more current audits, providers and hospitals will see a huge uptick in record requests from their risk adjustment payers. If release of information is currently done by in-house staff, your team will be slammed, as the timeframe for payers to submit supporting medical records has been tightened as well, from 22 weeks to 12 weeks. Let your contract management staff know that they will likely see contract changes issued, and to be on alert for penalties for failure to turn around requests in a timely manner.
In the meantime, the recapture of billions of taxpayer dollars is hanging out there, and coding professionals hoping to jump onto the government’s payroll seem to have been put on pause. Whether Dr. Oz was just spouting rhetoric or whether the hiring delay is just a hiccup, remains to be seen.
It finally happened! The Centers for Medicare & Medicaid Services (CMS) finally released the 2026 Outpatient Prospective Payment Final Rule on Friday at 4:15 pm,
Well, it’s what we’ve all been waiting for… In a late-night move last Wednesday, Nov. 12, President Trump signed the Continuing Appropriations Act (CAA) of
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