The Centers for Medicare & Medicaid Services administers Risk Adjustment Data Validation, or RADV, audits of Medicare Advantage organizations. The process samples enrollee medical records to test whether diagnosis codes that raise risk scores—and therefore monthly payments—are supported in the chart.

According to CMS rulemaking, a 2023 final regulation authorizes the agency to extrapolate error rates from those samples to entire Medicare Advantage contracts for payment year 2018 and later. Agency materials describe the change as aligning RADV with other Medicare integrity tools.

The Department of Health and Human Services Office of Inspector General has published a series of audits of Medicare Advantage risk-adjustment payments. Those reviews typically selected high-risk hierarchical condition categories, examined supporting documentation, and projected results. Public OIG reports have estimated billions of dollars in payments that lacked adequate medical-record support in the years examined.

CMS officials have said RADV, not inspector-general sampling, is the statutory mechanism for recoupment from Medicare Advantage plans. The agency has begun notifying contracts of audit findings and has posted timelines for record submission and dispute.

The inspector general’s office has separately reviewed CMS’s use of contractors to retrieve charts, code records, and calculate error rates across Medicare programs. Public OIG work has described incomplete recoveries, delayed recoveries, and gaps in how CMS monitors contractor performance against statements of work.

The Government Accountability Office has noted that CMS took years after a 2012 RADV demonstration to issue extrapolated findings. GAO testimony and reports in the public record cite staffing, methodology disputes, and litigation risk as factors in the lag.

Medicare Advantage enrollment, according to CMS monthly reports, now covers more than half of Medicare beneficiaries. Risk-adjusted payments form a large share of the program’s annual outlays, which exceed $400 billion in recent CMS budget documents.

Medicare Advantage organizations and industry groups have argued in public comments that CMS chart-review standards and coding intensity differ from those applied in OIG audits. Plans have also challenged extrapolation methodology in administrative appeals and federal court filings.

The record shows CMS did not adopt every OIG recommendation on sample design, diagnosis targeting, or the treatment of “chart reviews” that plans themselves submit. CMS has stated that RADV follows a statistically valid sample and that plans may rebut findings with additional documentation.

Contractors performing RADV medical-record review operate under CMS task orders. OIG reports on related Medicare integrity contractors have found instances in which quality-assurance sampling, timeliness metrics, or recoupment tracking were incomplete. Those findings appear in published audit reports rather than classified annexes.

CMS has said it has strengthened contractor oversight and that RADV recoveries will increase as the 2018 and subsequent payment-year audits close. The agency has not published a single public ledger that reconciles every OIG projection with every RADV recoupment.

Inspector-general officials have, in congressional testimony, described Medicare Advantage improper-payment estimates as a persistent high-risk area. They have recommended that CMS complete RADV cycles more promptly and that contractor statements of work include clearer recovery and reporting requirements.

Public dockets show CMS receiving thousands of pages of comments on the 2023 RADV rule from plans, provider groups, and state insurance departments. Many comments focused on the shift from fee-for-service error-rate assumptions to Medicare Advantage-specific extrapolation.

The 2011 through 2013 payment-year RADV audits, according to CMS notices, produced limited extrapolated recoveries relative to later OIG estimates for comparable periods. Subsequent payment years remain in various stages of record collection and dispute.

HHS budget justifications list RADV as one of several program-integrity activities funded through the Medicare Integrity Program and related appropriations. Those justifications do not itemize contractor invoice totals against specific OIG findings.

No classified document is cited. The comparison rests on CMS final rules and audit notices, OIG reports posted on oig.hhs.gov, GAO publications, and enrollment and expenditure tables already in the public domain.

Litigation over RADV methodology continues in federal district courts. Plans have sought to enjoin or narrow extrapolation; the government has defended the 2023 rule as a lawful exercise of existing recoupment authority.

CMS has stated that unsupported diagnoses inflate taxpayer-funded payments and that RADV is intended to restore accuracy. The inspector general has stated that its own samples continue to find material unsupported coding even as CMS audits proceed.

Contractor performance remains a recurring theme in OIG Medicare work plans. Those plans, published annually, list ongoing reviews of medical-review contractors, recovery-audit contractors, and CMS’s monitoring of both.

The two streams of work—CMS RADV and HHS OIG contractor and payment audits—therefore sit side by side in the public record: one operational recoupment program still scaling, the other a set of published estimates and contractor critiques that have not been fully closed by recoveries to date.