Major changes are underway in the Medicare Advantage (MA) space — and while recent headlines may raise concerns, they also signal long-overdue reforms. A sweeping federal lawsuit alleging massive kickbacks in MA enrollment and a bold new audit strategy from the Centers for Medicare & Medicaid Services (CMS) are clear indicators that policymakers are taking meaningful steps to restore integrity, transparency, and fairness to the nation’s fastest-growing Medicare program.

For Florida’s home health providers, this moment presents both a challenge and an opportunity — and HCAF is working to ensure your voice shapes the path forward.

DOJ Lawsuit Alleges Massive Kickbacks in MA Enrollment

Earlier this month, the U.S. Department of Justice filed a landmark lawsuit accusing Aetna, Humana, Elevance Health, and several top insurance brokerages of paying hundreds of millions of dollars in illegal kickbacks to steer seniors into high-margin MA plans. According to the complaint, brokers prioritized profit over patient needs, leading to improper enrollments, denied services, and even discriminatory practices against people with disabilities.

These revelations validate long-standing concerns from providers — especially those serving medically complex and high-need patients — about the misaligned incentives and systemic barriers that often undermine the delivery of timely, appropriate, and coordinated care under MA.

CMS Unleashes Most Aggressive MA Audit Initiative in Program History

On May 21, 2025, CMS announced a historic expansion of its Medicare Advantage oversight efforts. Effective immediately, the agency will begin auditing all eligible MA contracts for each payment year going forward and fast-track the completion of overdue Risk Adjustment Data Validation (RADV) audits for payment years 2018 through 2024.

In the official announcement, CMS Administrator Dr. Mehmet Oz made the agency’s intentions crystal clear:

“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.”

Key elements of CMS’s new strategy include:

• Enhanced Technology: CMS is using advanced data analytics and machine learning to review medical records at scale, flagging diagnoses that lack proper documentation. These tools allow CMS to detect potential overpayments more efficiently and accurately.
• Workforce Expansion: CMS is increasing its team of medical coders from 40 to 2,000 by September 1, 2025. These coders will manually review flagged claims, enabling faster, more thorough audits across the entire MA program.
• Increased Audit Scope: CMS will now audit all 550+ active MA plans annually, up from just 50–60. It will also expand the number of records reviewed per plan from 35 to up to 200, allowing for broader oversight and more reliable extrapolation of findings.
• Backlog Elimination: CMS will clear its backlog of Risk Adjustment Data Validation (RADV) audits for payment years 2018-2024 by early 2026. This effort will retroactively assess whether past risk-adjusted payments were justified by supporting medical documentation.

This unprecedented expansion of scope, speed, and enforcement reflects mounting pressure to rein in $17 billion to $43 billion in estimated MA overpayments each year, as reported by the Medicare Payment Advisory Commission (MedPAC).

Florida’s Voice in Washington

Amid these sweeping changes, Florida providers have a powerful ally in Congress. U.S. Representative Vern Buchanan (R-FL), Chair of the House Ways and Means Subcommittee on Health, has strongly endorsed CMS’s audit strategy and reiterated his commitment to protecting both beneficiaries and the providers who serve them:

“Medicare Advantage plays a vital role in providing high-quality, affordable care to millions of seniors, including thousands in my district…Transparency in how these plans are audited and paid is crucial for maintaining trust in the system and the efficient use of taxpayer dollars.”

As a senior member of Congress serving in the majority, Congressman Buchanan’s support for greater accountability and financial oversight gives Florida providers a direct line into shaping how this new enforcement environment evolves.

What Providers Should Watch For

While the DOJ lawsuit and CMS audits focus primarily on insurers and brokers, home health agencies could still be impacted — especially if MA plans attempt to recoup clawbacks from downstream providers.

CMS has indicated that overpayments due to unsupported diagnoses may trigger recoupment efforts from contracted providers, depending on your agreement with the plan. This makes compliance, documentation accuracy, and proactive audit readiness essential in this evolving landscape.

HCAF urges providers to:

• Review contracts with MA plans for recoupment and audit liability language.
• Reinforce clinical documentation protocols to ensure diagnoses are fully supported.
• Strengthen internal compliance programs to prevent exposure during RADV audits.

The Bottom Line

As Medicare Advantage undergoes heightened scrutiny and long-needed reforms, HCAF is advocating for equitable reimbursement, streamlined authorization, and fair audit practices in partnership with the National Alliance for Care at Home.

Additionally, we are actively monitoring all developments to provide timely education, compliance guidance, and policy updates for members.

Stay tuned for upcoming advocacy opportunities and resources designed to support your success in this rapidly growing and shifting environment.