Preparing against CMS's RADV ramp-up

The Regulatory Shift MAOs Can’t Ignore

CMS recently announced an aggressive expansion of RADV audits across Medicare Advantage. The agency will now audit every eligible MA contract each payment year, increase sample sizes, accelerate backlog audits, and expand the coder workforce dedicated to review. CMS is signaling a clear direction:‍

RADV will be broader, faster, and far more consequential for MAOs going forward.‍

For decades, RADV has operated in a narrow window—targeted samples, limited scope, long delays. That era is over. The new reality demands stronger internal controls, higher documentation precision, and a renewed focus on last-mile accuracy in coding.

MAOs now face a regulatory environment where coding errors and documentation gaps can lead to materially larger financial exposure. Preparing early—and rigorously—is no longer optional.

What the RADV Ramp-Up Means in Practical Terms

The changes announced by CMS shift both the scale and the consequences of RADV:

• More audits for more plans: Every eligible MA contract will now be audited annually, instead of a small subset.
• Larger sample sizes: Plans should expect up to 200 medical records per contract per year, significantly increasing exposure.
• Faster timelines: CMS is clearing backlog audits (PY 2018–2024) by early 2026, which compresses response timelines for MAOs.
• Stricter documentation expectations: CMS is expanding its coder workforce and tooling, allowing for deeper scrutiny of supporting evidence.

The result: documentation and coding precision are now central to revenue protection, not just compliance hygiene.

Where MAOs Are Most Vulnerable

In our conversations with MA risk, compliance, and coding leaders, several patterns consistently emerge:

1. Last-Mile Coding Errors

Even when documentation is available, inconsistencies in MEAT criteria, ambiguous phrasing, or minor coder misinterpretations can trigger error findings during RADV review.

2. Documentation Gaps — Not Missing Codes

The issue is often not whether a code could be supported, but whether the underlying documentation meets CMS expectations.

3. Fragmented Internal Workflows

Retrospective review, prospective suspecting, and audit preparedness remain siloed in many organizations, increasing risk of conflicting evidence trails.

4. Limited Pre-Audit Readiness

Few MAOs routinely run internal mock audits to test how their documentation and coding would hold up to CMS scrutiny.

As RADV scales, these vulnerabilities matter more than ever.

A Practical RADV-Readiness Checklist for MAOs

This checklist is designed to give MAOs a concrete, operational framework to evaluate their preparedness. It can be used by RA leaders, compliance teams, and coding vendors alike.

Documentation & Evidence Integrity

• Confirm that your coding workflows consistently produce MEAT-defensible evidence for every submitted HCC.
• Ensure documentation sources are complete, traceable, and reproducible during audit.
• Validate that chronic condition continuity is well-supported across years—not assumed.

Internal Controls & Audit Simulation

• Conduct mock RADV audits annually (or biannually) using CMS-like sampling.
• Identify your highest-risk HCC categories and review evidence depth for each.
• Stress-test retrieval and response workflows against compressed timelines.

Coding Accuracy & Quality Assurance

• Implement independent dual-review or spot-check mechanisms focused on last-mile precision, not just throughput.
• Review error patterns and coder drift to ensure alignment with CMS coding guidelines.
• Maintain documentation and coding guidelines that reflect the newest RADV interpretations.

Operational Preparedness

• Index and centralize unstructured clinical notes for fast retrieval during audit.
• Align RA, compliance, and clinical documentation teams so responses are coordinated.
• Review provider engagement strategies for obtaining external chart documentation.

Technology & Data Readiness

• Ensure your systems can surface documentation reliably and consistently, with minimal manual handling.
• Validate that coding outputs are structured, reviewable, and audit-ready—not trapped in vendor-specific formats.
• Use technology to support accuracy and consistency, not replace expert oversight.

This checklist is intentionally vendor-agnostic — it reflects what CMS will expect from all MAOs, regardless of tooling. You can also download this checklist as a PDF.

How RAF Precision AI Supports RADV Readiness — and Its Limitations

RAF Precision AI was designed to strengthen last-mile accuracy, documentation consistency, and audit defensibility. In the context of RADV expansion, here is what our platform can—and cannot—do.

What RAF Precision AI Can Support

• MEAT-based evidence generation for each identified code, improving documentation defensibility.
• Detection of documentation inconsistencies that may create audit risk.
• High-precision code identification to reduce last-mile errors that lead to RADV findings.
• Efficient review workflows that help teams triage and validate documentation more quickly.
• Support for internal mock audits, providing structured evidence packets for testing audit readiness.

What RAF Precision AI Cannot Do

• It cannot fully replace coder or auditor judgment; human oversight remains essential.
• It cannot generate documentation that does not exist; if providers failed to document, no AI can fix that.

The Path Forward

RADV has entered a new phase — one defined by scale, speed, and heightened scrutiny. MAOs that invest early in documentation consistency, high-precision coding, and robust audit controls will be far better positioned to withstand the coming audit cadence.

Preparing for RADV isn’t just a defensive strategy. It’s an opportunity:

• to clean up internal workflows,
• to strengthen evidence quality,
• to improve member risk accuracy,
• and to build lasting operational resilience.

The strongest MAOs will treat RADV readiness as infrastructure, not a once-a-year fire drill.

If you want help assessing your RADV preparedness or exploring how RAF Precision AI can support your documentation and accuracy workflows, book a demo with us!