Preparing for a CMS Medicare Advantage Audit: Your Checklist

In a move to ensure payment accuracy, combat fraud, and strengthen program integrity, the Centers for Medicare & Medicaid Services (CMS) recently began intensifying its Medicare Advantage (MA) audit efforts. If you’re a compliance officer, risk manager, operations director, or other stakeholder with an MA plan or CMS-approved contractor, this means a dramatically broader scope and increased scrutiny for all eligible MA plans. Understanding these critical changes and proactively preparing is no longer optional — it’s essential to ensure compliance, protect your financial health, and safeguard your organization’s future.

What’s the Priority of These Audits?

CMS audits primarily focus on ensuring the accuracy of Risk Adjustment Data Validation (RADV), meticulously verifying that diagnosis coding that plans submit aligns with patient medical records. Audits also aggressively target fraud, abuse, and waste within the MA program. The overarching goal is to ensure proper payments and unwavering adherence to all federal regulations, impacting your bottom line directly.

Your Imperative for Proactive Preparation

With expanded audits and aggressive timelines — CMS aims to complete RADV audits by early 2026 — leaders need a robust and urgent strategy to prepare. That means strengthening your documentation practices, bolstering coding accuracy across all departments, and reinforcing your overall compliance framework as soon as possible. Proactive measures are the best way to mitigate the risk of adverse findings, significant financial penalties, and reputational damage. The time to act is now.

Partner with Medix for Immediate Audit Readiness

A trusted staffing partner for nearly 25 years, Medix provides immediate access to expert audit professionals, ensuring compliance, minimizing risk, and protecting your financial integrity and Star Ratings. We specialize in providing rapid access to pre-vetted, specialized talent, significantly reducing your hiring burden and accelerating your audit readiness.

Our efficiency is unmatched — our time-to-fill for open roles is 10.23 days, three times faster than the staffing industry average of 35 days. Contact us today to secure pre-vetted, specialized talent for audit teams, eliminating the hiring burden and accelerating your readiness.

CMS Medicare Advantage Audit Mandate Your Preparation Checklist

Sources:

1. “Medicare Advantage Contract-Specific Risk Adjustment Data Validation (RADV) Audit Methods and Instructions,” Centers for Medicare & Medicaid Services, November 14, 2024,  https://www.cms.gov/files/document/payment-year-2018-ma-radv-audit-methods-instructions.pdf.