Medicare AdvantageDocumentationHigh impact
CMS expands Medicare Advantage RADV audits to all eligible plans
UPMC Health Plan·Provider Announcement
Effective date
Jun 1, 2025
We identified it
Aug 7, 2026
Summary
CMS has significantly expanded its RADV (Risk Adjustment Data Validation) audit program effective June 2025, now requiring audits of ALL eligible Medicare Advantage plans (including UPMC Health Plan) for payment years 2019-2023, with medical record samples increasing from 35 to 35-200 records per plan annually. Providers will receive direct requests for medical records covering dates of service from 2018-2023 and must respond promptly with required documentation.
Action Required
Immediately: Establish a process to track and prioritize all RADV medical record requests from UPMC Health Plan and other Medicare Advantage plans. Designate a point person to receive requests and distribute to billing/clinical staff. By June 2025: Billing team must create a response protocol including: (1) timeline for locating and submitting medical records within CMS/plan-specified timeframes, (2) documentation checklist to ensure completeness (member information, dates of service, diagnosis codes, supporting clinical notes), (3) internal audit of high-risk diagnoses from 2018-2023 to identify potential documentation gaps before requests arrive. Train all clinical and billing staff on RADV requirements. Update EMR templates to ensure diagnosis codes are clearly documented and linked to clinical evidence. Failure to provide complete, timely responses to audit requests may result in extrapolated overpayment findings and recoupment demands from CMS.