Medicare Advantage just got a lot riskier. CMS, DOJ, and the OIG have turned their attention to upcoding and unsupported HCCs—and they’re not stopping at the plans. Under new audit rules, a single documentation gap could trigger millions in clawbacks, and in many risk-sharing arrangements, those financial penalties can fall directly on the providers.
Make sure your codes and your docs are covered
Medicare Advantage just got a lot riskier. CMS, DOJ, and the OIG have turned their attention to upcoding and unsupported HCCs—and they’re not stopping at the plans. Under new audit rules, a single documentation gap could trigger millions in clawbacks, and in many risk-sharing arrangements, those financial penalties can fall directly on the providers.
New rules. Real consequences.
CMS is ramping up Medicare Advantage audits. Under the updated RADV rule, they can now extrapolate audit findings across entire plan populations. That means a small error rate on a sample of charts can suddenly become a multi-million dollar problem. A $100,000 overpayment could quickly balloon into a $10 million clawback.
Even more concerning? In many risk-sharing or "pay-vider" arrangements, providers may be on the hook for part of that payback.
The DOJ, OIG, and CMS have all made it clear: upcoding and unsupported diagnoses are in the spotlight. Enforcement isn’t slowing down. For a real-world example, look to the Independent Health case: the DOJ fined the plan $100 million for improper HCC code submissions—errors tied directly to documentation gaps and inflated risk scores.
Audits aren’t coming—they’re already here
The takeaway is simple: health plans and providers are both under the microscope. CMS can now apply audit results across an entire enrolled population, and even small documentation gaps can lead to massive clawbacks. In contracts that tie provider revenue to coding accuracy, those penalties can follow the audit trail all the way to the physician.
Right now, 20% of Medicare Advantage claims are miscoded. About 30% of HCCs fail CMS validation because of missing or incomplete documentation. That's a lot of audit exposure.
⚠️ 20% of Medicare Advantage claims are miscoded
30% of HCCs fail CMS validation due to documentation gaps ⚠️
The process is the problem
Even the most diligent teams struggle with accuracy under pressure. Coders are operating at capacity, and providers are, rightly, focused on delivering care, not chasing codes. Manual reviews move too slowly to keep up with the volume. And HRAs, when not thoroughly documented, often introduce more audit exposure than value.
The bottom line? Accuracy is harder than ever—and the cost of getting it wrong is growing by the day.
Smarter reviews. Stronger defense.
So how do you make sure you're getting it right? That’s where Aptarro comes in. We built our HCC Coding Engine to do one thing: make compliance easier and faster for coders, providers, and plans alike.
Our HCC Coding Engine flags the gaps before they trigger an audit. It surfaces the highest-risk coding issues and helps coders focus where it counts, without adding to provider workloads. With Aptarro, compliance and revenue stop working against each other—they align.
It’s not about doing more. It’s about doing the right work, at the right time, with the right visibility.
Don’t wait around for an audit
CMS is cracking down. Extrapolation is here. The risk is real—for plans and providers. But getting it right doesn’t have to be complicated.
Talk to us about how we can help you!
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See how Aptarro’s HCC Coding Engine boosts RAF accuracy and maximizes revenue—without adding work for your team.