RADV & Compliance
Risk Adjustment Data Validation — the audit landscape, OIG enforcement, and compliance strategies
Source: CMS, HHS OIG, MedPAC, federal court filings • Last updated March 2026
Key Takeaway
RADV is CMS's primary enforcement tool for ensuring that MA plans' risk scores are supported by medical records. The program is undergoing its most aggressive expansion in history: from auditing ~60 contracts per year to all 550 eligible contracts, with a workforce growing from 40 to 2,000 coders. Although a federal judge vacated the extrapolation rule in September 2025, enforcement pressure continues and CMS is expected to reissue. Every MA organization should be preparing for audit now.
What Is RADV?
Risk Adjustment Data Validation (RADV) is CMS's audit program that verifies whether diagnoses submitted by Medicare Advantage organizations for risk adjustment are actually supported by medical records. If diagnoses cannot be validated, MA plans must repay the associated risk adjustment revenue.
RADV is separate from (but complementary to) the HHS Office of Inspector General's own audit activities. OIG conducts independent investigations and has been increasingly aggressive in flagging MA risk adjustment practices.
CMS Center for Program Integrity (CPI)
Social Security Act §1857(e); 42 CFR §422.311
All MA contracts (Part C); separate program for Part D
HHS-RADV for ACA Marketplace (45 CFR Part 153)
The $84 Billion Context
MedPAC estimates the federal government overpays MA plans by approximately 20% per beneficiary, totaling ~$84 billion in 2025. Risk adjustment is the primary mechanism through which this overpayment occurs. CMS has multiple levers to address this: the coding intensity adjustment (5.9%), RADV audits, model recalibration (V28), and the proposed exclusion of unlinked chart reviews ($7.2B). RADV is the enforcement backstop that validates all other risk adjustment inputs.
Contracts targeted
All eligible MA contracts
Audit coders
Up from 40 in 2024
Records unsupported
OIG sample finding
Est. annual overbilling
Federal estimates
RADV Program Timeline
Two Audit Ecosystems
CMS RADV (Medicare Advantage)
- Validates MA plan risk adjustment submissions
- Expanding to all 550 eligible contracts
- Extrapolation methodology under legal challenge
- PY2018–2024 audits in progress or planned
- CMS + OIG conduct separate audit streams
HHS-RADV (ACA Marketplace)
- Validates ACA issuer risk adjustment submissions
- Governed by 45 CFR Part 153
- Different methodology from CMS RADV
- Less publicized but growing in scope
- Administered by CMS/CCIIO