CMS Expands Medicare Advantage Audits: What the New Enforcement Push Means

CMS Announces a Major Expansion of Medicare Advantage Audits

The Centers for Medicare & Medicaid Services (CMS) has unveiled a sweeping expansion of its Medicare Advantage (MA) audit program, signaling a significant escalation in federal oversight. Under the new initiative, CMS will conduct annual audits of all 550 eligible MA contracts which is a dramatic increase from the roughly 60 plans reviewed each year in the past. Additionally, the agency has committed to clearing a year-long backlog of audits, prioritizing unresolved payment reviews from 2018 through 2024, with a completion deadline set for early 2026. 

As CMS increases Medicare Advantage audit scrutiny, organizations monitoring quality measures and Patient Safety Indicators (PSIs) may need to engage structured PSI service programs to address audit exposure and reporting requirements.

Why Medicare Advantage Insurers Are Facing Heightened Scrutiny

The announcement has sent shockwaves through the healthcare industry and financial markets, triggering swift backlash from major insurers. UnitedHealth Group and Humana, two of the largest Medicare Advantage (MA) providers, are now under heightened scrutiny, with UnitedHealth facing an active U.S. Department of Justice (DOJ) investigation into potential MA billing fraud. In an effort to preempt further regulatory action, both insurers have publicly endorsed reforms aimed at curbing the use of insurer-initiated home risk assessments. A controversial practice linked to inflated Medicare reimbursements. Analysts warn that such changes could reduce Medicare spending by as much as $124 billion over the next decade, dealing a significant blow to insurers that rely on these revenue streams. 

Preparing for Increased Oversight and Documentation Review

The expanded Medicare Advantage (MA) audit program marks a seismic shift in regulatory enforcement, fundamentally altering the compliance landscape for insurers and providers. Organizations must now brace for unprecedented documentation scrutiny, rigorous retrospective audits, and a far more aggressive federal oversight regime. To navigate this new reality, compliance programs require immediate reassessment, internal audit processes must be strengthened, and risk-sharing agreements should be reevaluated to mitigate the substantial financial and operational exposures stemming from this heightened oversight. 

Works Cited:

Centers for Medicare & Medicaid Services. (2025). CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits. U.S. Department of Health and Human Services. Available at: https://www.cms.gov/newsroom/press-releases/cms-rolls-out-aggressive-strategy-enhance-and-accelerate-medicare-advantage-audits

Wall Street Journal / Reuters. (2025). Humana to back curbs to Medicare Advantage billing practices, WSJ reports. Reuters (citing WSJ). Available at: https://www.reuters.com/business/healthcare-pharmaceuticals/humana-back-curbs-medicare-advantage-billing-practices-wsj-reports-2025-06-05/