Medicare Advantage Audits Expected to Rise in Face of Increased Federal Scrutiny
By Emma Freer

Based on a new rule and in response to heightened scrutiny, Medicare Advantage plans – and the physician practices that care for patients enrolled in them – should expect an increase in the number of audits related to such risk-sharing contracts.  

In response, the Texas Medical Association has developed free CME to help member physicians prepare for such audits, which could result in financial liability for practices. 

Since February, when the rule took effect, the Centers for Medicare & Medicaid Services (CMS) has had greater scope to conduct Medicare Advantage risk adjustment data validation (RADV) audits, which aim to reduce overpayment and improve the accuracy of diagnostic coding.  

In recent years, Medicare Advantage plans have been plagued by reports – and federal audit findings – of fraud, to the tune of $650 million in “improper payments” according to CMS estimates.  

“For years, federal watchdogs and outside experts have identified the Medicare Advantage program as one of the top management and performance challenges facing [the U.S. Department of Health and Human Services (HHS)], and today we are taking long overdue steps to conduct audits and recoup funds,” HHS Secretary Xavier Becerra said in announcing the rule.  

As a result of this policy change, Medicare Advantage plans and clinicians should implement best practices for documentation, perform their own billing compliance audits, and be prepared to respond promptly to any RADV audit requests, says Sabrina Skeldon. The former federal prosecutor and senior counsel to HHS’ Office of Inspector General worked with TMA to develop two webinars with more information about how to prepare:  

Browse TMA’s other CME offerings in the TMA Education Center.  

Last Updated On

September 20, 2023

Originally Published On

September 20, 2023

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Emma Freer

Associate Editor

(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

More stories by Emma Freer