CMS Audit Alert: Medicare Advantage Plans

The Center for Medicare & Medicaid Services (CMS) announced plans to expedite audits of all Medicare Advantage (MA) plans. The expedited audits will focus on payment years 2018 through 2024. It is also ramping up audits of all MA plans in the near term. Leading Age VP Nicole Fallon speculates that such audits could lead to further reimbursement rate reductions for home health providers. CMS expects to complete all outstanding Risk Adjustment Data Validation (RADV) audits for 2018 through 2024 by early 2026. To facilitate the audits, CMS is expanding its auditor workforce of medical coders to nearly 2,000 by September 2025. "We are committed to crushing fraud, waste, and abuse across all federal health care programs," commented Dr. Oz, CMS administrator. CMS currently audits 60 MA plans each year.

CMS will also increase the number of audits per plan year from 35 to 200. The audits seek to verify that the diagnosis reported by plans, which in turn determine payments, are supported by enrollees' medical records. Additionally, CMS will coordinate with the Department of Health and Human Services's Office of Inspector General to recover overpayments identified in previous audits.

For more information about the accelerated audit schedule, read here.