As contract-level Risk Adjustment Data Validation (RADV) audits ramp up, Medicare Advantage Organizations (MAOs) must understand a critical—and often overlooked—aspect of CMS’s audit methodology: there is no right to appeal the sampling or extrapolation methods used.

This isn’t just a technicality—it has major implications for audit readiness, financial liability, and how plans prepare for seven years of retrospective scrutiny.

What CMS Said: No Appeal Rights on Methodology

Per the CMS FAQ released in December 2023, CMS makes it clear:

“CMS will rely on any statistically valid method for sampling and extrapolation that it determines to be well-suited to a particular audit.”
— [CMS RADV FAQ, Q4, Dec 2023]

Unlike other administrative determinations, MAOs cannot appeal:

The specific sampling methodology used
The choice of extrapolation method
Confidence intervals or stratification techniques applied

While CMS will disclose its methodology to MAOs, this disclosure is informational—not subject to negotiation or appeal.

Why This Matters: Financial Risk Without Recourse

This policy creates a high-stakes environment:

Even if only a small number of sample records fail validation, extrapolation can magnify that error across the full contract population.
MAOs could face multi-million dollar recoveries based on CMS’s chosen extrapolation model—even if the methodology is different from one used in a prior audit.
There’s no procedural pathway for plans to challenge the validity, accuracy, or fairness of the sampling technique used.

CMS’s Flexibility in Audit Design

CMS has explicitly stated it is not adopting a one-size-fits-all audit design. Instead, for each contract-level RADV:

CMS will use audit-specific methods it considers statistically valid.
The exact sampling logic may vary by year, contract, or audit round.
CMS maintains discretion to adjust extrapolation logic based on circumstances.

This means historical comparisons or prior audit outcomes offer limited protection or precedent.

Preparing for a No-Appeal Audit Environment

Given the lack of appeal rights, MAOs must prepare on the front end:

Ensure medical record quality and completeness
Don’t rely on post-audit correction—CMS will use what you submit as-is.
Audit your sample logic internally
Run simulations using industry-standard statistical methods so you aren’t surprised by extrapolated outcomes.
Leverage technology to strengthen defensibility
AI tools like those in Health Data Max’s Risk Adjustment Platform can:
- Flag weak documentation
- Recommend stronger charts for submission
- Validate HCC support before records go to CMS
Educate coding and compliance teams
If they’re not aware that extrapolation choices are final, they may under-prioritize the strategic importance of each chart in the sample.

Final Thought

CMS’s “no appeal” position on sampling and extrapolation methodologies raises the bar for audit preparedness. The methodology may be beyond your control—but your data, documentation, and chart selection process are not.

Want to safeguard your revenue against RADV extrapolation? Let Health Data Max help you build audit resilience with data you can trust—and defend.