CMS Doubles Down on RADV Audit Changes

On January 27, 2026, the Centers for Medicare and Medicaid Services (CMS) released a Health Plan Management System (HPMS) memo that provided a long-awaited update on how the agency plans to approach previously announced Risk Adjustment Data Validation (RADV) audits for Payment Years (PY) 2020-2024. The memo is the agency’s most comprehensive statement on the subject since September 25, 2025, when the Northern District of Texas vacated the 2023 RADV Final Rule. The memo makes clear that, while CMS has made certain operational adjustments in response to concerns expressed by Medicare Advantage Organizations (MAOs), the agency is largely pressing forward with the accelerated audit strategy announced in May 2025.

Key Takeaways

• • Timing for upcoming audits: CMS intends to proceed with audits for PY 2020-2024, with new audits expected approximately every three months, starting in February 2026.
  • Medical record submission window: For PY 2019 audits initiated in the summer of 2025, CMS originally imposed a three-month medical record submission window, later extended to five months. In the memo, CMS announces plans to continue providing a five-month submission window for PY 2020 audits and beyond.
  • Sample sizes: CMS states that sample sizes will vary in the range of 35-200 enrollees based on contract size “or similar criteria” for PY 2020 and beyond, with smaller contracts less likely to be subject to a 200-enrollee sample.
  • Medical record submission limit: CMS is continuing to restrict the maximum number of medical records that can be submitted per audited Hierarchal Condition Category (HCC) to two, based on the agency’s view that only one valid medical record is needed to support payment.
  • Use of AI: CMS states that it is still “plan[ning] to secure” new AI technology to support medical coders but notes that coding decisions which could result in overpayment determinations will be made by “human certified medical coders.”
  • Transparency enhancements: CMS plans to redesign the RADV program webpages to better organize and publish important audit program documents, including the upcoming audit calendar, guidance documents, FAQs, and audit methods and instructions. 

What Medicare Advantage Organizations Can Do

Crowell & Moring stands ready to assist MAOs with questions or concerns about CMS’s evolving RADV audit strategy. Our team of veteran health care lawyers is prepared to provide support with compliance counseling, submission review, appeal strategy, and dispute resolution around emerging agency proposals.