Expect More Medical Record Requests from Medicare Advantage Plans
CMS has announced a major expansion of its Risk Adjustment Data Validation (RADV) audit program for Medicare Advantage (MA) plans. This effort delivers a significant expansion compared to historic audits that focused on only a select few MA plans. Starting June 2025, all eligible MA plans will be audited for payment years 2019–2023, with 35 to 200 medical records requested per plan, depending on size.
What to Expect
Our team is anticipating an increase of record requests from MA payers across the board as a result of this CMS initiative. Blue Cross NC has already notified providers that they would begin requesting charts in June 2025, covering dates of service from 2018–2023.
If your pathology practice or lab provided services to MA members during that time, it’s likely you’ll be contacted to supply documentation.
Why This Matters
This expansion, which for BCBS NC alone jumps from 60 to over 550 plans audited annually, reflects the heightened focus on risk adjustment accuracy. What should be top of everyone’s mind is that under the RADV Final Rule, CMS can extrapolate audit findings to recover overpayments.
How We’re Supporting Our Clients
Our team at MSN Healthcare Solutions is actively preparing for this change with our pathology and lab clients. From managing requests to obtaining supporting documentation for compliance, we’ll help make sure you’re ready when the time comes.
If you receive a medical record request related to this audit, contact us right away.
More Information
- Federal Register :: Medicare and Medicaid Programs; Policy and Technical Changes to the Medicare Advantage, Medicare Prescription Drug Benefit, Program of All-Inclusive Care for the Elderly (PACE), Medicaid Fee-For-Service, and Medicaid Managed Care Programs for Years 2020 and 2021
- Update: CMS audits Medicare Advantage medical records starting June 2025 | Blue Cross NC
Dyana Williams
MSN Pathology Revenue Cycle Manager
Dyana Williams is a seasoned healthcare operations leader with over two decades of experience in revenue cycle management, client strategy, and organizational change within the laboratory and physician services space. She has served in senior roles at national RCM firms and as a laboratory consultant, guiding diverse teams through vendor transitions, regulatory compliance, and challenging reimbursement environments while maintaining a strong focus on growth and integrity. Her core strengths include strategic consulting, navigating payer relationships, and shaping operational initiatives that deliver meaningful results. Dyana is recognized for her combination of wit, humility, and a results-oriented mindset that creates lasting value for teams and organizations alike.
