Overview:
On May 21, 2025, the Centers for Medicare & Medicaid Services (CMS) announced a Medicare Advantage (MA) Audit Expansion. This directly responds to growing concerns about over-billing in the MA program, with a particular focus on high-cost procedures. CMS is increasing the number of coding auditors and audits to improve accuracy and ensure compliance with federal guidelines.
Key Changes:
- Increase in Auditors:
CMS is ramping up its audit team from 40 to 2,000 coding auditors. This dramatic increase aims to tackle the growing complexity of Medicare Advantage claims and ensure that billing and coding practices align with regulations. - Expansion of Audits:
The CMS plans to increase the number of MA audits from 60 to 550 per year. These audits will target higher-cost procedures more likely to be prone to billing errors or over-billing. This is part of a broader effort to scrutinize the Medicare Advantage program to ensure that beneficiaries receive the appropriate care and that billing aligns with medical necessity. - Focus on High-Cost Procedures:
Most audits focus on high-cost procedures, which are often included but not limited to the following specialties:- Interventional Radiology (IR) procedures
- Cardiovascular procedures
- Surgical procedures that require significant hospital resources, including wound care
- Specialized diagnostics and treatments within Medicare Advantage plans
This heightened scrutiny is intended to identify over- and under-coding, inappropriate billing, and improper claims submissions, with a special emphasis on procedures that have historically been associated with higher rates of discrepancies.
Impact on Physician Practices:
As a result of this expansion, physician practices, especially those performing high-cost procedures, will need to be even more diligent in ensuring their billing and coding practices meet CMS guidelines. This includes making sure that:
- Documentation is accurate and complete, particularly for high-cost or complex procedures.
- Medical necessity is demonstrated, especially for procedures involving expensive treatments or interventions.
- Claims are appropriately coded, with correct CPT and ICD-10 codes that reflect the services provided.
Physician practices should also be prepared for potential audits, which may involve submitting medical records, billing statements, and other supporting documentation to validate the claims submitted for Medicare Advantage beneficiaries.
What You Can Do:
- Stay updated on the latest CMS policies and changes.
- Stay on top of the latest literature, ensuring clinical-based evidence is followed, including procedures without a CMS policy, i.e., Lower Extremity Revascularizations.
- Ensure standard of care treatment(s) are followed and documented prior to the intervention as appropriate. If a diagnostic test is bypassed, i.e., ABI, CTA, document the reason in the chart to substantiate MDM.
- Enhance documentation practices to support all billed services, especially for high-cost procedures.
- Review your practice’s billing procedures regularly to ensure compliance with Medicare Advantage guidelines.
- Prepare for audits by ensuring your staff is familiar with the audit process and what documentation will be required.
Conclusion:
- With increasing audits and coding auditors, now is the time to ensure your practice is ready for the upcoming changes in MA audits.
- To avoid common pitfalls and ensure that your claims meet CMS guidelines, be proactive in your billing, coding, and documentation practices.
Reference:
CMS Rolls Out Aggressive Strategy to Enhance and Accelerate Medicare Advantage Audits | CMS
Related Blogs:
- https://streamlinemd.com/vascular-wound-care-billing-under-the-microscope-how-to-stay-audit-proof-in-2025/
- https://streamlinemd.com/for-healthcare-providers-cms-audits-can-be-a-daunting-reality-whether-it-is-a-rac-audit-looking-for-overpayments-a-cert-audit-measuring-error-rates-or-a-upic-audit-investigating-fraud-understandi/
- https://streamlinemd.com/2025-cpt-changes-for-radiology-interventional-cardiology-specialists/
- https://streamlinemd.com/oig-adds-lower-extremity-revascularization-procedures-to-2025-work-plan/
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