What Medicare Advantage Plans Need to Know About OIG’s Latest Oversight Priorities

The HHS Office of Inspector General (OIG) has recently released several reports and guidance documents that provide current and valuable insight into the agency’s current Medicare Advantage (MA) oversight priorities.  These publications signal increased scrutiny of prior authorization practices, risk adjustment accuracy, access to care, and delegated entity oversight. For MA organizations, they can also provide a roadmap for areas that may receive greater attention from regulators in future audits and rulemaking.

OIG’s New Medicare Advantage Compliance Guidance

In February 2026, OIG issued its Medicare Advantage Industry Segment-Specific Compliance Program Guidance (ICPG), the first major update to OIG’s MA compliance guidance in more than 25 years. The guidance identifies key compliance risk areas and outlines OIG’s expectations for effective compliance and oversight programs.

OIG’s key risk areas include:

• Access to care and utilization management
• Network adequacy and provider directory accuracy
• Risk adjustment and coding practices
• Marketing and enrollment activities
• First-tier, downstream, and related entity (FDR) oversight
• Data integrity and reporting accuracy

Although the guidance is stated as voluntary, it reflects OIG’s current position on the controls, monitoring activities, and governance structures that MA organizations should have in place, and leads the way for OIG (and CMS) to conduct additional oversight and issue new requirements.

Prior Authorization Remains a Major Focus

OIG also recently released reports examining MA prior authorization practices for post-acute care services. One report found that while plans denied approximately 12% of skilled nursing facility admission requests, 95% of appealed denials were ultimately overturned in favor of the enrollee. OIG expressed concern that this may indicate that beneficiaries may have initially been denied medically necessary care.

These reports also highlighted a wide variation in denial rates among plans, higher denial rates among certain populations, and concerns regarding oversight of utilization management vendors and contractors.  The findings reinforce the importance of monitoring denial patterns, appeal outcomes, and delegated utilization management activities, all of which have been focus areas in recent CMS rulemaking and auditing.

Risk Adjustment Continues to Draw Attention

OIG is continuing to identify unsupported diagnosis submissions through its MA risk adjustment audits, with recent audits finding diagnosis codes submitted to CMS that were not supported by medical records, resulting in significant estimated overpayments. MA plans should continue to conduct monitoring and oversight in this area, with focus on documentation requirements, internal validation reviews, and vendor oversight where applicable.

Bottom Line

Recent OIG activity sends a clear message: Medicare Advantage oversight is expanding beyond traditional compliance reviews and into a deeper examination of access to care, utilization management, risk adjustment integrity, and delegated entity oversight. Organizations that proactively assess their programs against OIG’s latest guidance will be better positioned to reduce risk, strengthen compliance, and prepare for future regulatory scrutiny.

MA organizations should be asking:

• Are denial and appeal trends regularly monitored and analyzed?
• Can we demonstrate effective oversight of delegated vendors and FDRs?
• Are risk adjustment submissions fully supported by medical record documentation?
• How well does our current compliance program align with the new OIG ICPG?
• Would we be prepared if CMS or OIG requested evidence of our monitoring and oversight activities tomorrow?

OIG MA ICPG Compliance Tracking Tool

To help MA organizations evaluate their level of compliance with the OIG ICPG recommendations,  BluePeak Advisors has developed an OIG MA ICPG Compliance Tracking Tool that provides a summarized view of the OIG expectations, an outline of where those expectations intersect with CMS MA requirements, and a process for tracking Plan activities that demonstrate adherence.

The assessment translates OIG’s expectations into a practical operational review that can quickly outline the steps an MA Plan has taken toward meeting OIG expectations and where the MA Plan may have opportunities to improve.