Payer Policy

Medicare Advantage RADV Audits Reach Full Scale for 2026

Every RADV-Eligible Contract, Every Year, With Extrapolation Under CMS-4185-F2

Rcmaxis Billing & Policy Update  ·  Posted October 9, 2026  ·  Effective: Payment Year 2018 forward (RADV final rule effective April 3, 2023)

CMS has moved from sampling a rotating group of roughly 60 Medicare Advantage contracts to auditing every RADV-eligible contract every year, with extrapolated findings applied back to payment year 2018 and no Fee-for-Service Adjuster to offset the result.

Summary of the Rule Change

CMS finalized the Risk Adjustment Data Validation program's current methodology in the Medicare Advantage Risk Adjustment Data Validation final rule, CMS-4185-F2, published in the Federal Register on February 1, 2023, and effective April 3, 2023. The rule settled two points that had been unresolved for years: CMS will extrapolate RADV audit findings starting with payment year 2018 forward, and it will not apply a Fee-for-Service Adjuster that would otherwise reduce the extrapolated recovery amount. For 2026, CMS has scaled audit operations to match, reviewing every RADV-eligible MA contract annually rather than a rotating sample, backed by a significantly expanded certified coding review workforce.

The effect is cumulative, not a one-time event. A contract audited in a prior cycle isn't exempt going forward, and the extrapolation methodology means a relatively small sample of unsupported diagnoses can generate a contract-wide repayment demand. CMS has not published a single fixed sampling or extrapolation methodology; it uses whichever statistically valid approach it determines is well-suited to a given audit.

RADV liability sits with the Medicare Advantage organization, not the billing practice directly. But the plan's audit exposure is built entirely from the documentation practices submitted on its behalf, which is why risk-sharing and value-based MA contracts increasingly push chart-level documentation standards and retrospective review down to the practice.

Action Required for Practices Billing Risk-Bearing MA Panels

Practices under Medicare Advantage risk-sharing, capitation or value-based arrangements should treat 2026 as the year their chart documentation is assumed to be part of an active audit population, not a hypothetical one. The MEAT documentation standard, Monitor, Evaluate, Assess, Treat, is what RADV reviewers use to validate whether a submitted HCC is supported.

  • Run a self-audit on your highest-weighted HCCs. Diabetes with complications, CHF, COPD and major depressive disorder carry enough weight that gaps there drive the largest extrapolated exposure.
  • Confirm every chronic HCC was recaptured this calendar year. A condition documented last year but not addressed with a MEAT element this year won't validate.
  • Ask your MA plan partners what their RADV sample included last cycle. If your patients were in the sample, your documentation gaps are already known to the plan.
  • Code to FY2026 ICD-10-CM specificity. Under the fully phased-in V28 model, an unspecified code is more likely to miss the HCC mapping than it was in earlier models.

Our guide to HCC risk adjustment coding in 2026 covers the V28 model's full phase-in and the MEAT standard in detail, including two real OIG audit examples showing how extrapolation turns a chart-level documentation gap into an eight-figure repayment finding.

Verifiable References

  1. Centers for Medicare & Medicaid Services. Medicare Advantage Risk Adjustment Data Validation Final Rule (CMS-4185-F2) Fact Sheet. cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet
  2. Federal Register. Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Benefit Programs (88 FR 6643), February 1, 2023. federalregister.gov/documents/2023/02/01/2023-01942
  3. Electronic Code of Federal Regulations. 42 CFR 422.311, Risk adjustment data validation audits. ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-G/section-422.311
  4. Centers for Medicare & Medicaid Services. Risk Adjustment. cms.gov/medicare/payment/medicare-advantage-rates-statistics/risk-adjustment

Related Resources

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