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What Are Medicare Advantage Audits?

Medicare Advantage programs are more common these days, with a significant portion of Medicare beneficiaries currently enrolled in different programs.

Known commonly as MA plans, the Medicare Advantage programs are issued by Medicare Advantage Organizations (MAOs)—usually, insurance companies.

Why Medicare Advantage Audits?

Medicare beneficiaries are essentially attracted to MA plans because they offer additional coverage for little to no cost instead of the traditional Medicare program. At the same time, MAOs like the programs because they have risk-adjusted payments from Medicare. This means that an MAO will get additional income when they tend to patients with worse health conditions.

This structure, however, also presents a possibility for gaming the system. Some MAOs use additional diagnoses to attain high-risk scores, while not necessarily reflecting these diagnoses in any documentation.

Healthcare providers tend to have issues with MA programs. Payment and claim adjudication can occur through contracts that aren’t necessarily the same, which definitely differ from the rules and regulations found in traditional Medicare.

If a non-contracted healthcare provider is offering services, then the MAO makes a payment under traditional Medicare rules and regulations. This provides an opportunity to question how an MAO can adjudicate a claim under standard Medicare rules, while the MAO’s adjudication system has been developed to address claims.

While several entities are affected differently by how MA programs are being run, there’s always a point at which fraudulent activity could easily occur. This is especially true since there’s a risk adjustment process that essentially provides more payments to MAOs, including sicker patients. To ensure that the system is being run fairly, the Centers for Medicare and Medicaid Services (CMS) instituted Medicare Advantage audits.

As expected, the Medicare Advantage audits help to provide a level playing field in terms of payment claims and more. The audits focus on ensuring that MAOs don’t game the system and claim back more money than they should, while also seeing to it that they provide optimal levels of care to their patients.

Every year, the CMS selects several MA plans for Medicare Advantage audits. These audits are detailed and thorough, in line with their mission to ensure compliance with the CMS’s guidelines.

Preparing for a Medicare Advantage Audit

Nurse tucking in a patient on a hospital bed

The usual Medicare Advantage audit process will require that MA plans and MAOs submit reports and documentation that show their compliance with the CMS’s guidelines. There are also communication requirements and more that you will need to do.

The Medicare Advantage audit results will be made public, and they can have significant impacts on your practice. Fortunately, however, you have several guides that can help you make adequate preparations. There’s a CMS Medicare advantage audit guide that you can look through to ensure that you comply with all statutory laws. Even so, some healthcare providers struggle to gather the right amounts of data in a manageable, comprehensive manner.

The following tips will help you understand some significant points to note as you prepare for your audit.

Develop a Data-driven Operation

In today’s healthcare space, almost everything revolves around data and information. This is the same with a Medicare Advantage RAC audit and other types of government audits. Speaking truthfully, you won’t be able to cram anything that will help you with the audit at the last minute. However, with the right information around, you can make sure that the audit is a success.

Most audit processes will require long lists of documentation and files. This means that if your practice is still relying on manual data management processes or disparate systems, you’ll most likely be at a disadvantage. Your audit process will include lots of decision-making tasks, and there won’t be much time left to waste. So, build a data-driven approach that will help you to ensure that you have everything you need.

Develop a Comprehensive Audit Playbook

Man auditing and looking at paperwork

One of the many benefits of the CMS Medicare advantage audit guide is that it provides an opportunity for you to understand the right compliance processes. You can also manage your operations better to ensure compliance and move faster from there.

So, why not build a playbook to help you out? Essentially, your audit playbook is a rundown of activities that will help you plan the right policies for staying compliant with the Medicare Advantage audits. The playbook will include methods of collecting and logging data, as well as how to best present your information to auditors. It will also have copies of the administrative policies and procedures you use when making critical decisions.

Ensure Consistent Improvement With Mock Audits

It might seem like a waste of time, but you want to ensure that everyone who works at your practice is equipped with what they need to get through a Medicare Advantage audit successfully. So, once in a while, conduct mock audits to keep your workers on their toes.

Mock audits will help to make sure that your practice is in full compliance with the CMS Medicare advantage audit guide. You need to ensure that the culture of compliance is embedded in your decision-making and work culture.

At the same time, mock audits will help you to maintain visibility into your administrative processes and member relationships. This will ensure that you deliver the best level of service to customers, whilst preparing you for Medicare Advantage RAC audits and any other possible assessments from the CMS.

The CMS audit itself will most likely be a lengthy, time-consuming process. However, your mock audit doesn’t necessarily need to be the same. You can easily continue to operate efficiently without committing your staff members to several hours of mock audits. The objective is to ensure that everyone is confident in being prepared for an actual audit when it comes.

The truth about the Medicare Advantage audits is that they can happen at any time. Being prepared isn’t easy, especially since audits take a lot of time and effort. However, by following these tips, you can ensure that audits will never catch you off-guard.


If you are subject to a Medicare Advantage audit, use precision in selecting an attorney to defend you. You’ll need a veteran team with full mastery over the subject to properly get you organized and maintain compliance.