Risk Adjustment & Integrity

CMS is intensifying risk-adjustment and program-integrity pressure under the Trump administration, with RADV scaling from a limited set of MA contract reviews to broad audit exposure and recent MA audits estimating more than $202 million in overpayments for Humana and UnitedHealthcare—raising the stakes for documentation, coding governance, and pre-audit chart validation across MA plans and risk-bearing providers. At the same time, CMS is pairing integrity enforcement with market-transparency proposals, including public Medicare Advantage provider-directory accuracy scores and PBM flat-fee requirements, signaling that VBC stakeholders will face tighter scrutiny not only on risk scores but also on network adequacy, administrative data quality, and downstream contracting economics. For ACOs and health systems, the emerging pattern is clear: audit readiness and data integrity are becoming core operating capabilities, not compliance back-office functions, as reinforced by current RADV readiness guidance and payer-focused coverage of scaled CMS RADV audits and CMS’s MA directory/PBM transparency proposals.