Understanding the Impact of the CMS-HCC Phase-In and RADV Audits

Risk adjustment services for Medicare Advantage organizations are now operating in a materially different environment. The three-year phase-in of the 2024 CMS-HCC (V28) risk adjustment model is complete – meaning 100% of risk scores for non-PACE Medicare Advantage organizations are now calculated under the updated model [1]. At the same time, CMS has initiated RADV audits for Payment Years 2020, 2021, and 2024 [2] increasing the scrutiny on whether submitted diagnosis codes are supported by the medical record. For organizations managing Medicare Advantage risk adjustment, the combination of a fully implemented model and expanding audit activity creates a clear operational priority: accuracy from the point of documentation through every stage of the risk adjustment process.

CMS began introducing the V28 model in 2024 and increased its use gradually over three years.

For non-PACE Medicare Advantage organizations, that transition is now complete. CMS is calculating 100% of risk scores using the V28 model. The updated model includes changes to condition categories, more recent diagnosis and expenditure data, and other technical updates intended to improve the model's predictive accuracy [3].

CMS projects a 2.10% MA risk score trend for 2026, based primarily on historical diagnosis coding patterns – while noting that actual experience can vary between individual plans.

This makes accurate diagnosis capture essential. The focus should not be on capturing more diagnoses. It should be on making sure every reported diagnosis is supported by the patient's medical record – because under the fully phased-in model, unsupported codes carry the same audit exposure they always did, with no further transition period to absorb corrections.

CMS has significantly increased its audit activity in 2026, initiating RADV audits for three payment years within the same calendar year.

On March 20, 2026, CMS notified Medicare Advantage organizations of contracts selected for Payment Year 2020 RADV audits. On May 29, 2026, CMS initiated Payment Year 2021 audits. On August 28, 2026, CMS announced the start of Payment Year 2024 RADV audits [2].

CMS has published audit methods, instructions, schedules, and lists of audited contracts for each of these payment years.

For organizations whose contracts are selected, this audit environment puts direct attention on whether the medical record supports the diagnoses submitted for risk adjustment. For organizations not currently selected, the expanded audit program signals the standard of documentation accuracy that CMS is enforcing across the MA market.

With the updated HCC model fully in place and RADV audits active across multiple payment years, organizations need a consistent and documented approach to risk adjustment services. That includes:

• Accurate diagnosis coding aligned with the V28 model
• Complete medical record review supporting each submitted condition
• Documentation validation confirming that medical records support reported diagnoses
• Regular quality checks identifying coding gaps and documentation inconsistencies before they reach audit
• Structured audit preparation for organizations with active or anticipated RADV reviews

This is also where well-designed risk adjustment solutions create measurable operational value – by connecting documentation, coding, review, and audit preparation into a single workflow rather than treating each as a separate activity.

Effective risk adjustment solutions focus on accuracy from the beginning – not retrospective correction after an audit finding.

Organizations need processes that connect documentation, coding, review, and audit preparation rather than treating each activity separately. A strong review process also identifies patterns and areas where additional education or quality improvement may be needed – building prevention into the workflow rather than responding to errors after submission.

For organizations managing risk adjustment audits as a recurring operational function rather than an event, this integrated approach creates both better audit outcomes and stronger ongoing coding accuracy.

3Gen Consulting provides risk adjustment services focused on accurate coding, documentation review, quality assurance, and audit readiness.

Our support includes:

• Prospective, concurrent and retrospective chart review
• HCC coding review aligned with the V28 model
• Documentation validation
• Quality assurance and ongoing feedback
• Risk adjustment audits preparation
• Education and improvement cycles

The focus is on supported and accurate diagnosis capture – not simply increasing the number of reported conditions.

For healthcare organizations operating in a Medicare Advantage environment where the V28 model is now the full standard and RADV audits span multiple payment years simultaneously, accurate risk adjustment services are the foundation that protects both reimbursement accuracy and audit readiness. Connect with 3Gen's risk adjustment specialists.