What Hospitals Should Expect from CMS Audits in 2026

As CMS tightens oversight and expands its program integrity efforts, hospitals and outpatient organizations should expect a noticeable increase in audit activity throughout 2026. These audits are not only tied to the new OPPS and ASC Final Rule but also to CMS’s broader focus on accuracy, transparency, and financial stewardship across Medicare programs.

Understanding where CMS is focusing its attention will help organizations prepare documentation workflows, reduce audit-related denials, and protect reimbursement.

High-Risk Service Lines Will Face Closer Review

CMS has consistently identified certain services as high-risk for improper billing or unexplained growth. In 2026, the following areas are likely to see the most scrutiny:

• Wound care and skin substitute services

• Chronic care management

• Emergency department visits

• Behavioral health integration

• Outpatient surgeries newly shifting from inpatient settings

Hospitals should confirm that documentation supports medical necessity, coding accuracy, and frequency of services for these categories.

Price Transparency and Billing Alignment Will Be ComparedAs transparency enforcement increases, CMS audit teams will now have a new tool: your hospital’s publicly posted price files.

Expect CMS to check:

• Whether posted standard charges align with actual billed charges

• Whether the pricing logic used publicly matches internal systems

• Whether updates occur as required

Discrepancies between published prices and claims data can trigger audits quickly.

Site-of-Service Documentation Will Matter More

With the ongoing phase-out of the inpatient-only list and payment alignment across settings, CMS will review whether services billed as outpatient truly meet clinical guidelines.

Key areas of concern include:

• Documentation supporting outpatient appropriateness

• Accurate use of modifiers

• Pre-surgery evaluations

• Consistent clinical pathways

Organizations should revisit policies to ensure teams are aligned with the newest CMS standards.

Providers Will See More Pre- and Post-Payment Reviews

CMS contractors are expected to increase both types of reviews, particularly in areas showing unexplained volume growth.

Hospitals should expect:

• More requests for documentation

• Shorter timelines to respond

• Tighter scrutiny of clinical notes

• Increased denials for insufficient detail

Preparation now reduces operational stress later.

Data Integrity Will Become a Central Audit Theme

CMS is giving auditors access to more cross-referenced data than ever before. This means they can compare:

Pricing files to claims

• Service utilization to national benchmarks

• Hospital performance to peer groups

• Documentation trends across specialties

Hospitals with inconsistent data will see more review activity.

How Hospitals Can Prepare

Proactive steps significantly reduce the risk of audit findings and denials:

• Review high-volume outpatient services for documentation consistency

• Validate alignment between transparency files and charge capture

• Standardize clinical documentation expectations by specialty

• Strengthen communication between compliance, billing, and clinical departments

• Use analytics tools to monitor internal outliers before CMS identifies them

As program integrity efforts expand, preparation becomes a strategic advantage.

If your organization needs support reviewing documentation workflows or identifying operational risks ahead of 2026 audits, MRS is here to help.