By Michael Egbert, Chief Executive Officer, Sherpas Healthcare Solutions, Guest Contributor

CMS has scaled Risk Adjustment Data Validation (RADV) to a degree the industry has never seen before. A program that once reviewed a relatively small pool of roughly 60 Medicare Advantage (MA) contracts a year now applies to all RADV-eligible contracts, roughly 550 of them, backed by a review workforce CMS said would expand from roughly 40 coders to approximately 2,000. Plans can no longer treat “retrieve the records once the request arrives” as a workable posture. When every eligible contract can be reviewed every year, waiting for the letter stops being a strategy and starts being an exposure.

The organizations that will deliver complete, defensible charts are the ones treating records retrieval and documentation review as everyday healthcare data operations, months before any request arrives.

The Scale Has Changed; the Clock Has Not

CMS has cited federal estimates that unsupported diagnoses account for roughly $17 billion in annual Medicare Advantage overpayments. Separately, MedPAC has estimated that coding intensity increased Medicare Advantage spending by roughly $43 billion in 2023. Those figures measure different aspects of the broader payment-integrity problem, but both help explain why CMS has significantly expanded RADV oversight.

The pace is no longer theoretical. CMS initiated Payment Year 2020 RADV audits in March, Payment Year 2021 audits in May, and Payment Year 2024 audits in August. Payment Year 2023 is currently scheduled to follow in November, with additional audit years already scheduled into 2027. CMS is now publishing a running audit calendar so organizations can plan against a known schedule rather than reacting audit by audit.

By CMS’s own accounting, completed audits for payment years 2011 through 2013 found overpayment rates in the 5-8% range. The mechanism matters more than the rate. Under the 2023 RADV Final Rule, findings from a sample could be extrapolated across a contract, and the fee-for-service adjuster that once absorbed baseline documentation variance was removed. A federal court vacated that rule in September 2025, and the legal picture is still unsettled. So, nobody can tell you today what the final recoupment math will look like, but every organization can control whether the underlying records exist, are findable, and are complete. That work is the same under any ruling.

Meanwhile, requests across many audited plans converge on the same provider population, the same retrieval support capacity, and the same limited shared resources, and that overwhelms the manual methods most organizations have relied on for chart retrieval and validation.

That convergence lands hardest on the provider side. A health plan under audit is managing one program: its own. A multi-site practice or community health center, meanwhile, is managing record requests from every plan running one, often with the same front desk and the same headcount it had last year.

Readiness Is Built Upstream

Audit readiness is not a project that begins once the notification letter is opened, and it cannot be built retroactively. It’s the result of decisions made months earlier, such as:

• How documentation is structured
• Who owns the workflow from intake to submission
• Whether retrieval relationships with providers already exist, or have to be built from cold
• Whether release of information is treated as a data operation or an afterthought

Organizations that wait until the clock starts running will discover that it takes far longer than expected to locate and review charts across disparate systems and to get full organizational cooperation to assemble a submission properly. Whether the deadline is measured in weeks or months, the window is not generous when the infrastructure needed to produce those records does not yet exist.

What Standing Retrieval Capacity Delivers

What changes when the capacity already exists is concrete. The retrieval and review steps have been run before, so the first attempt under deadline isn’t the first attempt ever. Provider relationships are warm rather than cold, which matters enormously when a records clerk at a two-provider practice is fielding requests from four plans in the same month. Records can be located, reviewed, and delivered without a last-minute scramble. And the medical records and coding staff who would otherwise be chasing charts can continue supporting patient care.

Building the retrieval capacity removes the failure mode where a defensible chart exists and simply isn’t produced in time.

From Fire Drill to Standing Operation

For 15 years, Sherpas Healthcare Solutions has worked alongside providers, payers, and retrieval partners, and that experience has reinforced one consistent truth: the organizations that perform best under audit pressure, whether it’s RADV or any other type of medical record review, are the ones that have made records retrieval a standing part of provider and payer operations rather than an episodic response.

The current RADV surge will eventually ease as CMS catches up on prior audit years. But the broader shift is lasting: every Medicare Advantage plan will continue to face RADV audits each year. With broader scope and a larger review workforce, plans and providers that continue to rely on reactive, ad hoc retrieval will be at a growing disadvantage to those with proactive documentation processes and a consistent, auditable approach to record retrieval.

Audit readiness is determined well before the first chart request arrives. Organizations that build that foundation now – and maintain it – are better positioned to respond with execution instead of improvisation. In a program where every eligible contract can be reviewed every year, that advantage compounds over time.

About Michael Egbert

Michael Egbert is President and owner of Sherpas Healthcare Solutions, where he has spent nearly 15 years working at the intersection of healthcare data, technology, and operations. He works closely with providers, payers, and health information management teams to improve how health information is retrieved, exchanged, and managed.

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