What CMS Audit Rule Means For Medicare Advantage Plans
Law360, 2026
Risk Adjustment Data Validation (RADV) is a sampling method used by the Centers for Medicare & Medicaid Services (CMS) to ensure that diagnosis codes submitted by Medicare Advantage providers are supported by patient records. RADV audits are at the center of an ongoing litigation dispute over the Medicare Advantage program, as well as False Claims Act cases. Any changes that may result from litigation could prompt disputes over how alleged overbilling is measured, how RADV samples are drawn, and how reliable audit results are.
In a Law360 article, Analysis Group Managing Principals Stephen Fink and Brad Rice and Vice President Igor Karagodsky summarize CMS’s announced RADV changes, discuss policy tradeoffs, and highlight statistical considerations for Medicare Advantage plans. The authors explain that while stronger oversight could encourage better documentation and coding controls, expanded sample sizes and a broader scope may raise the stakes for how audit statistics are applied. They note that extrapolation could substantially increase plans’ financial exposure by applying a small sample’s results to tens of thousands of enrollees. Because that might magnify even minor statistical errors, statisticians and health economists can play an important role in assessing the reliability of CMS’s methods and claims going forward.