Continuing its efforts to reduce fraud, waste, and abuse in Medicare, the Centers for Medicare & Medicaid Services (CMS) has announced plans to significantly enhance Risk Adjustment Data Validation (RADV) auditing in Medicare Advantage (MA). Beginning immediately (2025), CMS will audit all eligible MA contracts for each payment year going forward.
CMS intends to expand the audits in two ways: 1) by increasing the size of each contract sample from 35 enrollees to between 35 and 200 enrollees, depending on the size of the contract, and 2) by moving from auditing approximately 60 contracts per year to auditing all contracts every year.
Additionally, CMS announced it plans to complete all RADV audits for payment years 2019 through 2024 by early 2026. To complete both the old and new audits, CMS will use “enhanced technology,” such as artificial intelligence, to review medical records and flag unsupported diagnoses. It also plans to increase the number of medical coders from 40 to approximately 2,000 to review flagged diagnoses.
Implications for Oncology Practices
Because the number of RADV audits will increase significantly, medical record requests from MA organizations will also increase significantly. Providers will increasingly be expected to produce medical records that substantiate the relevant diagnosis and that have been signed by an appropriate provider, including the provider’s credentials.
Clinicians may also be expected to complete attestations when an acceptable medical record is not identified. Some providers may be asked to produce medical records for large numbers of patients if they contract with multiple MA organizations, or if the same contract is selected for audit in multiple years.
When medical records are requested, it is the responsibility of the billing provider to submit the requested documentation. A lack of proper or complete documentation can invalidate the services reported, potentially resulting in claim denials or overpayment issues.