By Jeannie Hennum, General Manager Value-Based Care, Verisma
November 3, 2026
Risk Adjustment Data Validation (RADV) teams within organizations participating in Medicare Advantage and Affordable Care Act (ACA) markets have been looking forward to the end of 2026 with fingers crossed, hoping for a modicum of relief from the audit pressure they’ve been under.
But the audit pileup is likely to continue. Two factors contribute to the load:
- Centers for Medicare & Medicaid Services (CMS) will maintain its shift from auditing about 60 Medicare Advantage (MA) contracts a year to auditing all eligible contracts (roughly 550) with samples of 35 to 200 enrollees each.
- CMS’s “catch up efforts” will spill over into 2027. Audit recoveries and extrapolation-related activities were delayed for about eight years and health plans are now feeling the agency’s mad scramble to overcome the backlog.
The amped-up audit schedule likewise tests health plans’ relationships with providers. To validate a condition for Hierarchical Condition Category (HCC) risk adjustment, health plans identify the one best medical record supporting the diagnosis and submits it for validation. These records, of course, must be retrieved from providers.
So, while MA RADV and ACA Health and Human Services-RADV are separate programs, they often compete for the same coding, compliance, provider, and record-retrieval resources.
The stakes are high: CMS historically audited PY2007 contracts and then experienced years of delays in broader recovery actions, despite federal estimates of about $17 billion a year in overpayments from unsupported diagnoses. Various industry analyses have estimated MA overpayments at tens of billions of dollars annually, reinforcing CMS’s motivation to intensify RADV oversight.
Q4: The Pressure is Real
Based on CMS’s published schedule and audit instructions (which, of course, are subject to change), three payment-year audits are touching the same teams this quarter.
Payment year 2021 records are due Nov. 6. Payment year 2024’s record window runs from mid-September to Feb. 5, 2027. And payment year 2023 audits are scheduled to begin in November, over the holidays, when provider offices and health information management (HIM) teams are thinnest.
(To add to the confusion, CMS is running the audits out of order, with 2024 ahead of 2023 and 2022, so the payment year number alone won’t indicate what’s due when.)
2027: Where it Compounds
Once the New Year’s party hats and noise makers have been put away, RADV teams unfortunately will find overlapping deadlines and new pressures to address. January brings payment year 2022 audits, on top of the 2023 and 2024 deadlines noted above. Then, in April, payment year 2025 audits begin, just as the 2023 window closes.
Within the same timeframe, the HEDIS record review season opens, which draws on many of the same providers supplying one best medical record for the audits. By spring, individual providers could be overloaded, facing several audits and quality reporting at the same time.
Why RADV Audits are so Taxing
Besides the volume of audits, this game of historical catchup means health plans must retrieve older records. Many factors could make those records hard to find. Perhaps they were never saved electronically or were lost under extreme circumstances like hurricanes or wildfires. Others may have been archived “somewhere” when providers converted from one EHR to another or were merged with another healthcare organization.
Even when the one best medical record is located, simply retrieving the record within the audit timeframe may not be enough. A single flaw – like a wrong member or date of service, a missing signature or credentials, an invalid source, or no evidence the condition was monitored, evaluated, assessed or treated – can lead to the HCC being invalidated and the payment recovered.
Relieving the Pressure
As RADV pressure continues, health plans are turning to partners like Verisma to ease the demands on their internal teams and reduce provider friction.
Retrieval-only and vendor-neutral, Verisma’s Retrieval IQ™ for Health Plans combines a centralized platform with highly trained experts to request, track, ingest, and quality-check medical records across provider networks. It’s built to scale with audit waves like the current RADV surge – handling provider outreach, chart chasing, and documentation collection so internal MA teams can stay focused on review and submission deadlines.
Plus, Verisma offers a Re-Chase program specifically for charts that have already been marked incomplete, rejected or stalled by another vendor or internal team – which carries greatest impact in the final stretch before upcoming RADV deadlines. It runs on a pay-for-success model, so there’s no cost unless Verisma retrieves the record.
RADV will keep evolving, but the requirement won’t: a valid record for each audited diagnosis, on time. Getting started with a proven partner like Verisma now will yield fast results in upcoming months and well into the future.
