CMS’s recent announcement to audit every Medicare Advantage (MA) plan annually marks a major shift in oversight, with a clear focus on ensuring that diagnoses, especially those identified during In Home Assessments (IHA), are fully supported by medical records and documented care. This expansion, which represents a shift from auditing about 60 plans a year to all 500+ MA plans, is backed by a rapid scale-up of CMS’s medical coder team and the use of enhanced technology to scrutinize records for risk adjustment validation.

This represents a heightened risk to health plans, particularly regarding diagnoses made during IHAs that are not followed by documented, in-network specialist care. The Medicare Payment Advisory Commission estimates up to $43 billion in annual overpayments stem from diagnoses not backed by sufficient medical records. For health plans, the exposure is clear: without evidence of follow-up care, diagnoses from IHAs may not withstand audit scrutiny, potentially leading to significant claw backs from CMS.

ReferWell’s solutions are purpose-built to address this exact challenge. Our advanced scheduling and care navigation platform enables health plans to seamlessly coordinate and document specialist follow-up visits after an IHA, ensuring that every diagnosis is substantiated by actionable, auditable care. By engaging members, scheduling them with the right in-network providers, and closing the loop with clinical documentation, ReferWell helps plans:

• Proactively demonstrate “evidence of care” post-IHA, supporting risk adjustment coding with real medical records.
• Close care gaps and improve member outcomes by ensuring timely specialist follow-up.
• Streamline compliance and reduce administrative burden with real-time reporting and analytics on care transitions and referral completion rates.

As CMS accelerates its audit strategy, health plans need to act decisively. Partnering with ReferWell means you can confidently demonstrate that every diagnosis, especially those made during IHAs, leads to documented, quality care. Let’s work together to turn compliance into an opportunity for better outcomes and stronger member trust.