During the 2026 National Provider Conference in Charlotte, NC, The Centers for Medicare & Medicaid Services (CMS) officials outlined the agency’s evolving approach to medical review, contractor oversight, and program integrity, emphasizing a shift toward targeted audits and provider education rather than broad enforcement actions.
The session featured remarks from CMS Division of Medical Review Director Dan Schwartz, who provided attendees with an overview of the Medicare contractors responsible for reviewing claims, identifying billing vulnerabilities, and ensuring compliance across the Medicare program.
CMS Promotes Education-Focused Review Strategy
Schwartz described how CMS has transformed its medical review efforts over the past decade. Earlier audit initiatives often relied on broad reviews and larger claim samples. Today’s review programs, he explained, are increasingly data-driven and focused on identifying specific billing risks while providing providers with opportunities to improve documentation and compliance.
“Our goal is to reduce billing errors and improve program integrity,” Schwartz indicated during the presentation, highlighting that education has become a central component of CMS review activities.
The agency’s review framework now incorporates several types of oversight activities, including:
- Prior authorization reviews
- Pre-claim reviews
- Prepayment reviews
- Postpayment reviews
Each review type is designed to address potential billing risks at different stages of the claims process.
Role of Medicare Administrative Contractors
A significant portion of the presentation focused on Medicare Administrative Contractors (MACs), which serve as CMS’s frontline contractors for claims processing and medical review activities.
According to Schwartz, MACs function as operational hubs responsible for:
- Processing Medicare claims
- Conducting medical reviews
- Analyzing billing data
- Identifying potential vulnerabilities
- Providing provider education
- Supporting appeals activities
MACs use claims analytics and data mining tools to identify trends, prioritize resources, and target reviews toward areas where improper payments or documentation errors may be occurring.
Targeted Probe and Educate Remains Key Initiative
CMS officials highlighted the continued importance of the Targeted Probe and Educate (TPE) program, a review model designed to improve provider compliance through focused education.
Under the TPE approach:
- Reviewers typically examine a small sample of claims.
- Providers receive individualized feedback.
- Educational sessions are offered to address documentation deficiencies.
- Up to three rounds of review may occur.
- CMS evaluates whether improvement has been achieved before determining next steps.
Schwartz noted that claim samples often range between 20 and 40 claims, allowing providers to correct issues without undergoing large-scale audits.
National Contractors Address High-Risk Areas
The presentation also reviewed the work of the Supplemental Medical Review Contractor (SMRC), a national contractor that conducts specialized reviews on behalf of CMS.
Unlike MACs, which operate within designated jurisdictions, the SMRC works nationwide and performs projects directed by CMS. Reviews are often initiated based on:
- Data analysis
- Program integrity concerns
- Emerging trends
- Oversight priorities
The contractor examines whether services billed to Medicare meet coverage, coding, and documentation requirements.
Recovery Auditors Continue Seeking Improper Payments
Another major area of discussion involved Recovery Audit Contractors (RACs), which are tasked with identifying Medicare overpayments and underpayments.
RACs conduct:
- Automated reviews using claims data
- Complex reviews requiring medical records
- Officials explained that these contractors focus on identifying improper payments and ensuring Medicare funds are used appropriately.
- Examples discussed included reviews of services that should occur infrequently, making them more susceptible to billing errors or abuse.
Providers Voice Frustrations
During the question-and-answer portion of the session, providers raised concerns regarding administrative burdens associated with audits and documentation requests.
One attendee described challenges encountered during a contractor review that involved substantial medical record submissions, equating to 60,000 pages of documents. According to the provider, electronic file transfers failed, USB media submissions were unsuccessful, and the contractor ultimately requested tens of thousands of pages of printed records within a short timeframe. The provider estimated that expedited shipping costs alone could exceed $20,000.
CMS representatives acknowledged the challenges and stated that efforts continue to improve documentation exchange processes and technology capabilities.
Communication with Auditors Draws Criticism
Another attendee expressed frustration with difficulties contacting Recovery Audit Contractors directly.
The provider said RAC representatives can be difficult to reach compared with other Medicare contractors, particularly when attempting to resolve questions or clarify documentation requests.
In response, CMS officials encouraged providers to use contractor contact channels and referenced the agency’s Medicare medical review mailbox as an option for escalating concerns.
Delays in Review Outcomes Raised
Questions were also raised about prolonged audit timelines. One attendee reported waiting approximately a year for results related to an ambulance-services review.
While CMS officials did not discuss the specific case publicly, they indicated that providers experiencing unusually long delays should pursue the matter through appropriate contractor and CMS communication channels.
Key Takeaway
The message from CMS was clear: Medicare oversight remains robust, but the agency increasingly favors a targeted, education-oriented approach aimed at improving provider compliance before pursuing broader enforcement actions. While providers continue to express concerns about audit burdens, documentation requirements, and communication challenges, CMS officials emphasized that accurate documentation, timely responses, and engagement with educational resources remain the best defense during a review.