The Centers for Medicare & Medicaid Services (CMS) has announced a major expansion of its audits of Medicare Advantage (MA) plans. Effective immediately, CMS will audit all eligible MA contracts for each payment year in all new audits and aims to complete audits for 2018–2024 by early 2026. This initiative addresses concerns over MA overpayments, estimated between $17–43 billion annually.
Key elements of the plan include:
- Technology upgrades to efficiently review medical records.
- Workforce expansion from 40 to 2,000 medical coders by September 2025.
- Increased audit volume from 60 plans annually to all 550 eligible plans, with audits of 35–200 records per plan.
CMS will also work with the HHS Office of Inspector General to recover past overpayments. The effort reflects CMS’s commitment to combat fraud, waste, and abuse and ensure accurate billing in MA plans.
We encourage providers to conduct compliance audits of all HCC reporting to MA plans to verify appropriate documentation and coding. The certified coding and compliance experts at HBE Advisors have extensive experience conducting HCC audits and are available to assist you with these audits.
The CMS announcement is available at: https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits