Addressing CMS's Aggressive Expansion of Risk Adjustment Data Validation Audits

Centers for Medicare & Medicaid Services (CMS) is intensifying its oversight of the Medicare Advantage (MA) program, leveraging artificial intelligence (AI) and advanced technology to expand Risk Adjustment Data Validation (RADV) audits both in scale and speed.

Healthcare organizations should recognize that any audit CMS initiates can have significant financial implications, and the agency’s approach is increasingly assertive.

Recent announcements from CMS indicate plans to:

• Eliminate the RADV audit backlog dating back to 2018 by early 2026, demonstrating a commitment to an aggressive audit timeline.

• Conduct audits on all eligible Medicare Advantage plans annually, moving beyond previous practices of auditing only samples.

• Apply extrapolation methods to audit payments, meaning errors found in sampled records may be assumed to exist across the broader dataset, potentially leading to large recoupments.

This shift places heightened pressure on healthcare organizations to ensure consistent compliance across all records, rather than relying on manual sampling and infrequent self-audits.

Verbal, a leader in healthcare AI compliance, enables organizations to meet this challenge by providing AI-powered self-auditing tools capable of reviewing 100% of patient records and interactions. These tools identify documentation gaps, compliance risks, and billing errors at scale, helping organizations proactively prepare for CMS audits and reduce financial exposure.

As CMS adopts AI-driven audits, healthcare organizations are advised to leverage similar technologies to maintain compliance and safeguard revenue integrity.

View Waleed Mohsen's full post here:

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