SNF operators should anticipate increased medical record requests from MA plans preparing for RADV audits covering payment years 2018–2024, and should review MA contracts for claw-back provisions that could expose providers to repayment demands if diagnoses used to set plan payments are found to be unsupported.
CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits
CMS will audit all eligible Medicare Advantage contracts annually and accelerate completion of audits covering payment years 2018–2024 by deploying advanced technology to review medical records and identify unsupported diagnoses, expanding its medical coder workforce from 40 to approximately 2,000 by September 1, 2025, and increasing the number of MA plans audited from roughly 60 to all 550 eligible plans annually. Federal estimates suggest MA plans overbill approximately $17 billion annually, with MedPAC estimates reaching as high as $43 billion per year. “We are committed to crushing fraud, waste and abuse across federal healthcare,” said CMS Administrator Dr. Mehmet Oz.
— Centers for Medicare & Medicaid Services, 21 May 2025“CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits.” CMS.gov. Centers for Medicare & Medicaid Services, 21 May 2025. https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits
CMS Presses Ahead on Accelerated Medicare Advantage Audits
The Centers for Medicare & Medicaid Services is moving forward with an accelerated audit program targeting Medicare Advantage plans, focusing on Risk Adjustment Data Validation audits that examine the accuracy of risk adjustment data submitted by MA insurers.
— Healthcare Dive, 4 February 2026
CMS Releases Update on Medicare Advantage RADV Audit Plans
CMS expects Payment Year 2020 RADV audits to commence in February 2026, continuing a broader acceleration effort for payment years 2018–2024 announced in May 2025. CMS has implemented several improvements addressing industry concerns, including restoring the five-month medical record submission period, scheduling audits every three months with a published calendar to minimize overlapping requests, and introducing AI-assisted coding support tools while maintaining human reviewer decision authority. Providers should request clarification from plans regarding whether documentation requests relate to RADV audits or other reviews for proper workload prioritization.
— AHCA/NCAL, 29 January 2026
CMS Overhauls RADV Audit Program for Medicare Advantage Plans
Many MA plans are already requesting medical records for audit preparation and response, creating increased documentation demands with compressed turnaround times. Potential claw-back clauses in MA contracts may allow plans to recover identified overpayments from providers. Valid diagnoses require clear documentation that is signed, dated, includes provider credentials, and demonstrates clinical evaluation and care integration — incomplete or vague records may result in disallowed diagnoses and repayment demands.
— Provider Magazine, 27 August 2025
Nursing Homes Welcome CMS Audits of Medicare Advantage Plans Amid Billions in MA Overpayments
Nursing home stakeholders expressed cautious optimism about the CMS audit initiative, with Fred Bentley of ATI Advisory noting “there’s a sense that maybe there will be a more level playing field” for nursing home providers. AHCA/NCAL stated, “We look forward to working with CMS to ensure Medicare Advantage plans are upholding the promise made to America’s seniors.” Nursing home operators are unlikely to face reimbursement cuts from these audits — rather, the initiative signals regulatory oversight focused on MA plan accountability for upcoding and billing accuracy.
— Skilled Nursing News, 4 June 2025
Medicare Advantage audits are intensifying in both frequency and volume as CMS implements a plan to resolve the backlog of pending audits by 2026. The effort involves Risk Adjustment Data Validation audits, which examine the accuracy of diagnoses and risk scores submitted by Medicare Advantage plans — processes with direct implications for how plans are paid and how they manage relationships with downstream providers.
— The Rowan Report, 29 May 2025
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