CMS To Intensify Medicare Advantage Audits

Source and Credit: Home Health Care News, By Audrie Martin | May 28, 2025

The Centers for Medicare & Medicaid Services (CMS) announced that it is ramping up audits of all Medicare Advantage (MA) plans – which could possibly lead to decreased rates for home health providers.

CMS’s plan to audit all eligible MA contracts each payment year and expedite audits for payment years 2018 to 2024, announced last week, is not directed at providers but could lead to further reimbursement rate reductions for home health providers, according to Nicole Fallon, vice president of integrated services and managed care at LeadingAge.

Specifically, CMS plans to complete all outstanding Risk Adjustment Data Validation (RADV) audits for 2018 through 2024 by early 2026. To achieve this goal, it will use “advanced” technology to analyze medical records and pinpoint unsupported diagnoses. Additionally, it will expand its workforce of medical coders to nearly 2,000 by Sept. 1.

CMS plans to increase audits from about 60 MA plans each year to include all eligible MA plans annually. It will also move from auditing 35 records per plan per year to auditing between 35 and 200 records, depending on the plan’s size, according to the CMS.

“We are committed to crushing fraud, waste and abuse across all federal health care programs,” Dr. Mehmet Oz, CMS administrator, said in a statement. “While the administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”

These audits aim to verify that the diagnoses reported by plans and used to determine payments are supported by the enrollee’s medical records, according to Fallon.

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Gateway's views;

This appears to be a review of what CMS has paid the Medicare Advantage Plans and potentially not what the Plan paid the Home Health Provider. Although there are currently many medicals reviews being conducted across the industry our initial thought is that this may be similar to a CERT (comprehensive error rate testing) audit. The biggest question in our mind is...

Who will take the hit if the audit determines "improper payments" were made? The MA Plan or the Provider? Will the impact go beyond just a future reduction in the overall payment structure for the care we provide to MA patients?

We will continue to follow the progress and releases made by all outlets as this topic continues.