What the Pause Actually Means
In September 2025, a federal court ruling paused RADV extrapolation, the mechanism by which CMS would apply error rates found in a sample to a plan’s entire contract, calculating recoupment across the full membership rather than just the sampled records. The pause means CMS cannot currently enforce extrapolated recoupment. Audits continue. Findings continue. But the financial multiplier that turns a sample-based finding into a contract-wide recoupment demand is on hold.
Some plans interpreted this pause as relief. That interpretation is wrong. The pause is temporary and subject to resolution through ongoing litigation. When extrapolation resumes, and the regulatory trajectory suggests it will, CMS will have years of accumulated audit findings from the annual universal audits it’s been conducting since 2025. The data will be there. The methodology will be approved. And the recoupment calculations will apply retroactively to payment years already audited.
The Accumulation Problem
During the extrapolation pause, CMS continues auditing every contract annually. It continues finding discrepant codes. It continues documenting error rates. The difference is that those error rates aren’t yet being extrapolated to the full contract. When extrapolation resumes, plans with multiple years of elevated error rates face retroactive recoupment across all those years, applied to their full membership rather than just the sampled records.
The math is sobering. An OIG audit finding $7 million in overpayments from 271 sampled enrollee-years becomes a dramatically larger number when extrapolated across a plan’s full contract membership. If a plan has 50,000 members and a sample-based error rate of 85%, the extrapolated recoupment could reach hundreds of millions for a single payment year. Multiply that across the three or four payment years of accumulated audit findings during the pause, and the exposure is existential.
Plans that used the pause to clean their coding practices and reduce error rates will face manageable extrapolation when it resumes. Plans that treated the pause as a free pass will face accumulated exposure they can’t remediate retroactively.
What to Do During the Window
The preparation window has three priorities. First, reduce your current error rate. Run internal RADV simulations against your submitted data. Identify and remediate documentation gaps in high-risk categories. Remove unsupported codes proactively. Every code you clean now is a code that won’t contribute to your error rate when extrapolation arrives.
Second, build the audit response infrastructure for the scale extrapolation will require. When CMS extrapolates, the rebuttal process becomes critical because every overturned finding reduces the extrapolated recoupment across the full contract. Strong rebuttal capability, built on pre-preserved evidence trails and strategic record selection, converts individual code defenses into contract-wide financial protection.
Third, quantify your exposure. Model what retroactive extrapolation across accumulated audit findings would mean for your organization at various error rate levels. Present that modeling to leadership and the board. The numbers will clarify the urgency of using the preparation window rather than wasting it.
Preparation, Not Relief
The RADV extrapolation pause created a finite window to prepare, not a permanent reprieve. Plans that understand this are using the window to reduce error rates, build evidence infrastructure, and model their exposure. The radv audit in risk adjustment process continues uninterrupted during the pause. Findings accumulate. Error rates are documented. When extrapolation resumes, the plans that prepared will face manageable recoupment. The plans that didn’t will face the accumulated consequences of every year they treated the pause as permission to wait.
