The Centers for Medicare & Medicaid Services (CMS) is launching a sweeping crackdown on billing practices across all Medicare Advantage (MA) plans—an aggressive move that could ripple through the nursing home industry and reshape how skilled nursing operators navigate federal reimbursement. In a major policy shift announced Wednesday, CMS revealed plans to dramatically scale up audits of all MA plans to recover billions in alleged overpayments. Nursing home operators that contract with these plans—and rely on timely, predictable reimbursements—could soon find themselves in the crosshairs of intensified federal scrutiny. Until now, CMS has been auditing only about 60 MA contracts a year. That number is about to explode: starting this year, the agency will expand its audit scope to all 550 eligible Medicare Advantage plans annually. The audits will cover a backlog stretching back to the 2018 payment year, and some cases could trigger sizable clawbacks. “While the administration values the work that [MA] plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately,” said CMS Administrator Mehmet Oz, M.D. For skilled nursing facility (SNF) owners, this could mean long-awaited audits being resurrected—dragging old claims back into dispute and creating headaches around documentation and compliance, particularly in cases where MA plans retroactively adjust payments or delay authorizations. CMS says the initiative is part of a broader push to eliminate fraud, waste, and abuse. It’s backing the effort with serious muscle: a newly expanded army of 2,000 medical coders—up from just 40—tasked with verifying flagged diagnoses and reviewing patient records. And it’s not just CMS leading the charge. The Department of Justice is already criminally investigating UnitedHealth Group over MA billing practices, while the Department of Health and Human Services Inspector General will be responsible for recovering any identified overpayments. But while the federal government aims to recoup potentially billions in inflated MA charges, some industry insiders fear legitimate providers may get caught in the dragnet—especially smaller operators who rely on MA reimbursements to stay afloat. At the heart of the issue are “risk scores”—a method by which MA plans receive increased payments for sicker patients. CMS says some plans are gaming the system through “upcoding,” or inflating diagnoses to receive higher payments. Nursing homes that partner with such plans—especially through managed care arrangements—could find themselves unwittingly entangled in audit findings. A March report by the Medicare Payment Advisory Commission (MedPAC) estimated that MA plans may be overcharging CMS by as much as $43 billion annually. With the government eager to close that gap, industry experts say audits are likely to get much more aggressive—and less forgiving. The new audit approach won’t just affect insurers. Operators who provide clinical documentation, generate patient diagnoses, or submit data to MA plans may soon need to tighten internal review processes. Failing to do so could put them at odds with CMS or expose them to indirect financial losses if plan payments are reversed. Healthcare strategy firm Capstone said the move poses a particular risk to large carriers like Humana, UnitedHealth, CVS/Aetna, and Elevance Health—but also noted that downstream providers could suffer collateral damage if MA plans restructure contracts in response. For nursing home owners, the message is sobering: CMS is ramping up enforcement, and any facility that depends on Medicare Advantage reimbursements […]