Will Medicare Advantage audits affect you? What to know about the government’s new crackdown on overpayments
- Replies 0
If you’re enrolled in a Medicare Advantage plan—or simply want to understand how your healthcare dollars are being used—there’s an important update coming out of Washington.
The federal government is launching a major new effort to recover billions of dollars in overpayments made to Medicare Advantage insurers.
This move, spearheaded by the Centers for Medicare & Medicaid Services (CMS) during the Trump administration, could reshape how these private insurance plans are monitored and held accountable.
But what exactly is changing, and what does it mean for you?
Let’s walk through the key points, the timeline, and what you can do to stay informed.
Why Medicare Advantage is under the microscope
Medicare Advantage, also known as Part C, is a popular alternative to traditional Medicare.
These private insurance plans have grown rapidly in recent years, with over 32 million people enrolled as of 2024.
Between 2023 and 2024 alone, enrollment jumped by 7%, and by 2034, nearly two-thirds of all Medicare beneficiaries are expected to be in a Medicare Advantage plan.
Part of what makes these plans attractive is that the government pays insurers more for enrollees with serious health conditions—based on the diagnoses reported.
This system is designed to ensure patients get the care they need.
But it also opens the door to billing errors and, in some cases, intentional overcharges.
According to the Medicare Payment Advisory Commission, these overpayments may cost taxpayers up to $43 billion per year.
That’s money that could go toward better care, expanded services, or reduced premiums for seniors.
Also read: Health insurers’ rates skyrocket for Medicare–what this means for your wallet!
What’s changing under the new CMS plan
To address these losses, CMS is rolling out what it calls an “aggressive” plan to recover improper payments and prevent future abuse. Here’s how:
Also read: Is your Medicare coverage changing? Unveiling the latest update
Why it matters to you
Even if you’re not directly involved in how insurers bill Medicare, these changes can still affect you. Here’s why:
What you can do as a Medicare Advantage member
Most beneficiaries won’t notice any changes in their coverage during this audit process, but staying informed can make a difference:
Also read: Budget dilemma: Proposed cuts could hit Medicare and Medicaid, affect millions
A message from CMS leadership
Dr. Mehmet Oz, the administrator of CMS, emphasized the agency’s stance in a recent statement:
“We are committed to crushing fraud, waste, and abuse across all federal healthcare programs. While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”
CMS plans to complete all audits covering claims made between 2018 and 2024 by early 2026.
With billions potentially being recouped, this new initiative aims to restore trust, improve oversight, and better protect taxpayer money.
Read next: Are insurers profiting from your Medicare plan? New Trump DOJ lawsuit targets major insurance players
Have you ever found something off in your Medicare billing? Do you think these audits will help, or is more oversight still needed? Let us know in the comments—your experience could help others in our community navigate the same challenges!
The federal government is launching a major new effort to recover billions of dollars in overpayments made to Medicare Advantage insurers.
This move, spearheaded by the Centers for Medicare & Medicaid Services (CMS) during the Trump administration, could reshape how these private insurance plans are monitored and held accountable.
But what exactly is changing, and what does it mean for you?
Let’s walk through the key points, the timeline, and what you can do to stay informed.
The federal government is ramping up oversight of Medicare Advantage plans in an effort to recover billions in overpayments and improve accountability. Image Source: YouTube / Scripps News.
Why Medicare Advantage is under the microscope
Medicare Advantage, also known as Part C, is a popular alternative to traditional Medicare.
These private insurance plans have grown rapidly in recent years, with over 32 million people enrolled as of 2024.
Between 2023 and 2024 alone, enrollment jumped by 7%, and by 2034, nearly two-thirds of all Medicare beneficiaries are expected to be in a Medicare Advantage plan.
Part of what makes these plans attractive is that the government pays insurers more for enrollees with serious health conditions—based on the diagnoses reported.
This system is designed to ensure patients get the care they need.
But it also opens the door to billing errors and, in some cases, intentional overcharges.
According to the Medicare Payment Advisory Commission, these overpayments may cost taxpayers up to $43 billion per year.
That’s money that could go toward better care, expanded services, or reduced premiums for seniors.
Also read: Health insurers’ rates skyrocket for Medicare–what this means for your wallet!
What’s changing under the new CMS plan
To address these losses, CMS is rolling out what it calls an “aggressive” plan to recover improper payments and prevent future abuse. Here’s how:
- Bigger audits, broader scope: Instead of reviewing only small samples of claims, CMS will now extrapolate audit findings to estimate overpayments across entire plans. The last time CMS attempted this type of large-scale recovery was in 2007.
- Every plan, every year: CMS will audit all 550 eligible Medicare Advantage plans annually, compared to about 60 in previous years.
- More auditors on the job: The CMS audit team is expanding from 40 to 2,000 staff members by September 1, 2025, to help process the growing volume of audits.
- New technology: CMS will use advanced systems to efficiently scan medical records and flag diagnoses that aren’t properly supported.
- Catching up fast: The agency aims to complete audits for payment years 2018 through 2024 by early 2026, tackling a major backlog that CMS admitted has left them “years behind.”
Also read: Is your Medicare coverage changing? Unveiling the latest update
Why it matters to you
Even if you’re not directly involved in how insurers bill Medicare, these changes can still affect you. Here’s why:
- It helps protect your benefits: Fraud and overbilling can drive up costs for everyone, potentially leading to higher premiums or fewer coverage options in the long run.
- It ensures fairness: When plans are paid properly, more resources stay available for programs and services that directly benefit seniors.
- It holds insurers accountable: With enrollment in Medicare Advantage continuing to grow, CMS says it’s time to ensure these plans are operating with integrity.
What you can do as a Medicare Advantage member
Most beneficiaries won’t notice any changes in their coverage during this audit process, but staying informed can make a difference:
- Read your plan communications: If your plan is audited, you may be contacted. Don’t ignore letters or emails from your insurer or CMS.
- Review your records: Check that your health conditions and treatments are accurately documented. Report errors to your healthcare provider.
- Speak up if something feels off: If you suspect your plan is billing for services you didn’t receive, contact Medicare at 1-800-MEDICARE or submit a report online.
Also read: Budget dilemma: Proposed cuts could hit Medicare and Medicaid, affect millions
A message from CMS leadership
Dr. Mehmet Oz, the administrator of CMS, emphasized the agency’s stance in a recent statement:
“We are committed to crushing fraud, waste, and abuse across all federal healthcare programs. While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”
CMS plans to complete all audits covering claims made between 2018 and 2024 by early 2026.
With billions potentially being recouped, this new initiative aims to restore trust, improve oversight, and better protect taxpayer money.
Read next: Are insurers profiting from your Medicare plan? New Trump DOJ lawsuit targets major insurance players
Have you ever found something off in your Medicare billing? Do you think these audits will help, or is more oversight still needed? Let us know in the comments—your experience could help others in our community navigate the same challenges!
