What’s New: CMS Is Getting Aggressive with MA Audits

In a significant announcement, the Centers for Medicare & Medicaid Services (CMS) outlined a comprehensive, fast-tracked audit strategy to improve oversight of Medicare Advantage (MA) payments.

Their top priority? Clearing the backlog.

CMS plans to complete all remaining RADV (Risk Adjustment Data Validation) audits from Payment Year (PY) 2018 through PY2024 by early 2026. For context — the last major RADV-based overpayment recovery was from PY2007. That means CMS is nearly two decades behind... and they’re now hitting the gas.

Here’s what this means in practice:

7 full years of audits (PY2018–2024) will be completed in less than two years
CMS is closing the gap on overdue recoveries
Expect clawbacks to ramp up as audits are finalized at scale

This is not just another oversight update — it’s an accelerated clean-up effort that will impact every Medicare Advantage plan operating in the last seven years.

Why This Should Raise Red Flags for Health Plans

This strategy isn't hypothetical. CMS has already begun using advanced analytics and broader review tactics to identify potential overpayments tied to inaccurate or unsupported diagnoses.

If your plan has legacy data, unvalidated codes, or documentation gaps between 2018 and 2024, you may already be under the audit spotlight.

Here’s what you’re up against:

Years of submissions under scrutiny at once
Increased risk of retroactive payment recovery
Higher administrative burden to compile and defend older records

Manual chart reviews, disconnected systems, and inconsistent coding standards simply won’t hold up during a retrospective audit that spans multiple payment years.

The Bigger Question: Can You Defend 7 Years of Risk Scores?

As we emphasized in this LinkedIn post, the question isn’t just whether your current workflows are working it’s whether your past submissions are defensible.

Ask yourself:

Do you have documentation to support diagnoses submitted in 2018 - 2024?
Can you trace coding decisions across older provider networks?
Are your historical encounter, chart, and claims data properly aligned?

If the answer is anything less than a confident yes, AI-powered tools can make all the difference.

Where AI Makes the Difference: Risk Adjustment, Reinvented

At Health Data Max, we’ve developed a modern, AI-driven risk adjustment platform designed to help MA plans gain full control — past, present, and future — of their data integrity.

AI-Powered Chart Validation

Detects unsupported or vague diagnoses
Prioritizes audit-defensible records for every payment year
Flags risks across multi-year submissions

Unified Data Management Across Payment Years

Ingests EDI 837s, claims, charts, eligibility, and provider attribution
Centralizes your PY2018–PY2024 data in one platform

Retrospective + Prospective Audit Readiness

Runs historical data through validation models
Identifies gaps and supports audit responses for every year in scope

Audit Simulation Tools

Stress-tests your risk score submissions
Prepares your team for CMS inquiries across multiple audit cycles

Why This Matters More Than Ever

Let’s be blunt: CMS is under pressure to recover funds — and your plan’s historical submissions are now fair game.

Whether it’s PY2018 or PY2024, your team must be ready to defend documentation and prove accuracy. Health plans that can’t trace a diagnosis back to solid clinical evidence risk:

Losing revenue
Facing clawbacks
Getting flagged for deeper compliance reviews

With the right AI tools, you can:

Validate data across all payment years
Surface the most reliable and compliant records
Build a strong audit defense — before CMS asks for it

Your 5-Step Audit Survival Plan for PY2018–PY2024

Aggregate All RA Data from PY2018–2024
Ensure you can access encounter, claims, chart, and attribution data for every year.
Run Retrospective AI Validation
Scan older submissions for unsupported HCCs or diagnosis codes.
Centralize Documentation
Make sure all supporting clinical evidence is retrievable and mapped to encounters.
Create an Internal RADV Response Playbook
Prepare audit response packs by year, by condition, and by provider.
Use Audit Simulation to Stay Ahead
Don’t wait for a notice. Run simulated audits to find and fix gaps in advance.

Final Thoughts: This Isn’t a Drill — It’s a Deadline

CMS is moving aggressively to clean up seven years of RADV audits in less than two. This isn’t a compliance suggestion — it’s an operational emergency for MA plans.

If you’re not fully integrated, validated, and audit-ready across PY2018 to PY2024, now is the time to act.

Because by early 2026, CMS will have already made up for lost time — and if your plan is out of sync, it could come at a serious financial and reputational cost.

Want to See How AI Can Audit-Proof Your Past Submissions?

Let’s help you build a risk adjustment infrastructure that defends your revenue — across every payment year.

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