CMS Launches Aggressive Medicare Advantage Audit Strategy: What Providers Must Know

The Centers for Medicare & Medicaid Services (CMS) has announced a sweeping initiative to enhance and accelerate Medicare Advantage (MA) audits, signaling one of the most aggressive enforcement actions in recent memory. This move carries major implications for Medicare Advantage organizations, providers, and Health Information Management (HIM) professionals.

Here’s what you need to know—and how to prepare.

Key Highlights of the Announcement

Nationwide Audit Expansion:

Effective immediately, CMS will audit all eligible MA contracts for each payment year in all newly initiated audits—a dramatic leap from the current scope of ~60 plans per year to over 550 plans annually.

Audit Backlog Targeted:

CMS is committed to completing all RADV (Risk Adjustment Data Validation) audits for Payment Years 2018 through 2024 by early 2026.

Workforce Scale-Up:

CMS will increase its team of medical coders from 40 to nearly 2,000 by September 1, 2025 to meet the audit demand and perform manual diagnosis validation.

Record Review Expansion:

Each MA plan audit will now review 35 to 200 patient records, depending on plan size—up from a flat 35 previously. This ensures statistically valid extrapolation of overpayments, aligning with the recent RADV final rule.

Advanced Technology Integration:

CMS will deploy AI-driven and automated tools to flag unsupported diagnoses and optimize audit review efficiency.

Collaboration with HHS-OIG:

CMS will work with the HHS Office of Inspector General to recover uncollected overpayments from prior audit cycles.

Why This Matters

Medicare Advantage plans are paid using a risk-adjustment model based on diagnosis codes submitted. The more severe or chronic the condition, the higher the payment.

But CMS has found a pattern of unsupported or inaccurate coding, and the stakes are high:

• Estimated overpayments range from $17 billion to $43 billion annually
• RADV audits from 2011–2013 revealed 5%–8% in overpayments

To rein in fraud, waste, and abuse, CMS is moving fast—and extrapolating audit findings, meaning a small error in a few charts could lead to millions in recoupments.

What HIM Professionals and Providers Must Do

This crackdown demands a proactive approach. Here’s how HIM professionals, practice managers, and providers can prepare:

1. Audit-Proof Your Documentation

Make sure every diagnosis code is clearly supported by medical record documentation. Vague or missing evidence will likely be flagged and disallowed.

2. Conduct Internal RADV-Style Audits

Simulate a CMS audit within your organization. Review charts from past years and validate diagnoses to assess exposure.

3. Reinforce Coding Accuracy

Invest in training programs and compliance refreshers for clinical and coding staff. Focus on chronic condition documentation, HCC coding, and risk-adjusted payment principles.

4. Streamline Medical Record Retrieval

Organize your EHR workflows to quickly access and submit records during an audit. Speed and transparency matter.

5. Consider External Audit Support

Partnering with an experienced HIM or Revenue Cycle Management firm can provide critical support—from audit prep to documentation improvement and appeals management.

The Bottom Line

CMS has made it clear: Medicare Advantage plans and their downstream providers are under heightened scrutiny. With advanced technology, a larger audit team, and a broader review scope, the agency is poised to recoup billions in overpayments—and ensure documentation and medical billing integrity.

Providers and HIM leaders who act now will be in the best position to stay compliant, mitigate risk, and protect revenue.

Need Help Preparing for RADV Audits?

At Bristol, we specialize in medical coding audits, documentation reviews, and risk adjustment coding services. Our certified experts help practices and MA plans stay ahead of regulatory audits and maintain compliance.

Contact us today to schedule a documentation review or learn more about our audit readiness solutions.