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CMS Rolls Out Aggressive Accelerated Medicare Advantage Audit Plan

The Situation Report | June 2, 2025

The U.S. Centers for Medicare and Medicaid Services (CMS) has announced intentions to significantly expand and accelerate audits of Medicare Advantage (MA) plans. According to CMS, beginning immediately, it will audit all eligible MA contracts for each payment year in all newly initiated audits and expedite its completion of audits for payment years 2018 through 2024.

In particular, CMS intends to conduct Risk Adjustment Data Validation (RADV) audits to confirm that diagnoses used for payment are supported by medical records.

CMS states that it is several years behind in completing these audits with the last significant recovery occurred following the audit of payment year (PY) 2007. The Medicare Payment Advisory Commission (MedPAC) estimates that “overpayments” could be as high as $43 billion per year. CMS’s completed audits for PYs 2011–2013 considered between 5% and 8% as overpayments.

The Administration plans to complete all remaining RADV audits for PY 2018 to PY 2024 by early 2026. Key elements include:

  • Enhanced Technology: CMS will deploy advanced systems to review medical records and flag unsupported diagnoses.
  • Workforce Expansion: CMS will increase its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses for accuracy.
  • Increased Audit Volume: CMS plans to increase its audits from 60 MA plans a year to all eligible MA plans each year in all newly initiated audits (approximately 550 MA plans), and from auditing 35 records per health plan per year to between 35 and 200 records per health plan per year in all newly initiated audits based on the size of the health plan.

CMS has stated that it will collaborate with the Department of Health and Human Services Office of Inspector General (HHS-OIG) to recover uncollected overpayments identified in past audits.

HCANYS is meeting with our federal advocacy affiliates in Washington to further evaluate the audit’s approach and implications, including in combination with other federal program and budget reforms under discussion in the Administration and Congress, and will advise the membership accordingly.