CMS Deputy Chief Operating Officer John Czajkowski | cms.gov/about-cms/leadership/deputy-chief-operating-officer
The Centers for Medicare & Medicaid Services (CMS) has announced an expansion of its auditing efforts for Medicare Advantage (MA) plans. This initiative will involve auditing all eligible MA contracts each payment year and investing resources to expedite audits from 2018 to 2024.
"We are committed to crushing fraud, waste and abuse across all federal healthcare programs," said Dr. Mehmet Oz, CMS Administrator. He emphasized the importance of CMS executing its duty to audit these plans accurately.
Medicare Advantage plans receive risk-adjusted payments based on diagnoses submitted for enrollees, with higher payments for more serious conditions. To verify these claims, CMS conducts Risk Adjustment Data Validation (RADV) audits. Currently, CMS is behind in completing these audits, with the last significant recovery occurring after the 2007 payment year audit.
Federal estimates suggest that MA plans may overbill by approximately $17 billion annually, with some estimates as high as $43 billion per year. Completed audits for payment years 2011–2013 found overpayments between 5% and 8%.
To address this backlog, a plan has been introduced to complete remaining RADV audits for payment years 2018 to 2024 by early 2026. Key elements include enhanced technology for reviewing medical records, workforce expansion from 40 to about 2,000 medical coders by September 1, 2025, and increased audit volume.
CMS will collaborate with the Department of Health and Human Services Office of Inspector General (HHS-OIG) to recover uncollected overpayments identified in past audits. The agency reaffirms its commitment to ensuring compliance with federal requirements.
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