Stay informed with the latest compliance strategies, CMS updates, and tips to keep your healthcare team ahead.
KFF's analysis of the first public prior authorization postings puts MA denial rates, appeal reversals, and response times in the open. The same determination systems feed your ODAG universes, and the two accounts differ in ways worth being able to explain.
CMS's CY 2025 Part C and Part D report in full: the three audit-process pilots, six lessons from audits and enforcement evaluations, 14 CMPs totaling $1.54 million, the intermediate sanctions in effect during 2025, and what CMS says to prepare for next.
Every routinely submitted universe table across ODAG, CDAG, FA, SNPCC, and CPE in one reference: what each table captures, which tables CMS collects only on instruction, and the field conventions all sixteen share.
SNPE is the SNPCC census table, and two compliance standards are tested against every row of it. How the Standard 1.1 and 1.2 populations differ, why None and EXC-10 decide findings, and how to get your denominators right.
Universe is CMS's word, not a vendor's. What universe scrubbing software actually validates (structure, formats, timeliness logic, cross-table consistency), why IDS makes it matter, and seven questions for evaluating any tool in the category.
A single HPMS memo can touch six departments. Why spreadsheet-and-email memo tracking breaks down, what the 2026 audit changes mean for your evidence trail, and what a closed-loop guidance workflow looks like.
A former Medicare Advantage Chief Compliance Officer's 30-day playbook for the first month after a 2026 CMS program audit engagement letter arrives. Days 1-3, 4-10, 11-20, 21-30, plus cross-cutting readiness items.
A practical overview of how CMS oversees Medicare Advantage and Part D plans in 2026: program audits, the new CAR/Observation/IDS framework, the five universe protocols, CPE evaluation, and what audit-ready actually requires.
The Formulary Administration audit looks at what your PBM rejected, what got transitioned, and whether members were notified on time. A practical walkthrough of where most plans get tripped up.
A practical walkthrough of the Part D Coverage Determinations, Appeals and Grievances universe. Where it differs from ODAG, the timeliness rules that catch plans off guard, and the data quality issues we see most.
CMS is removing 11 measures from Star Ratings and scrapping the Health Equity Index reward. Here is what changed, what it means for quality bonus payments, and where oversight is shifting.
Why manually cross-referencing CMS memos to your P&P library creates audit exposure, and how AI-powered policy intelligence gives compliance teams a systematic, documentable process.
CMS posted nearly $2.9M in MA/Part D fines by early April 2025, matching all of 2024. Learn what's driving enforcement and how plans can strengthen compliance.
An independent service auditor evaluated our security controls and confirmed they operated effectively over time. Here's what a SOC 2 Type 2 report means for our customers and why it matters for health plans handling sensitive CMS data.
A practical walkthrough of all 5 ODAG universe tables: OD, Reconsiderations, Payment, Effectuations, and Grievances. Learn what each table captures, which fields matter most, and where plans commonly get tripped up.
With CMS eliminating audit scoring and ICAR/ORCA classifications, Invalid Data Submission (IDS) becomes even more critical. Learn what triggers IDS findings and how to prevent them before February 2026.
Learn how CMS SNPCC audits ensure Special Needs Plans deliver coordinated care. Understand the 13 CMS standards, HRA timeliness requirements, and how to build a proactive compliance program.
Under CMS's 2026 "Collaborating on Compliance" model, your COA universe becomes the foundation for every discussion with auditors. Learn what the 12 COA data elements mean, common gaps that undermine discussions, and how to prepare before February 2026.
CMS released their 2026 Program Audit Updates memo with significant changes: scoring eliminated, ICAR/ORCA classifications removed, new CPE evaluation approach, and evolved validation audit requirements. Here's what compliance teams need to know.
Learn how to systematically measure Third-Party Administrator performance in CMS universe file validation with actionable metrics to drive continuous improvement and reduce compliance risk.
Honoring the dedication of compliance professionals who safeguard healthcare integrity while navigating an increasingly complex regulatory landscape, including the dramatic expansion of CMS audits in 2025.
Learn how incident management systems help health plans conduct structured fraud, waste, and abuse investigations while promoting a culture of compliance.
The 2026 CMS Program Audit framework reset what compliance means for Medicare Advantage plans. Five challenges every MA compliance team faces this year, and how each maps to the new audit reality.
The two layers of CMS compliance requirements: the seven mandatory program elements at 42 CFR 422.503(b)(4)(vi), and the operational obligations they exist to keep in check, from determination timeliness to delegated entity oversight, plus how CMS verifies both.
How to prepare for a 2026 CMS Program Audit under the new CAR/Observation/IDS framework. Universe file validation, COA universe readiness, documentation requirements, and during-audit response.
What non-compliance actually costs Medicare Advantage plans: CMS CMPs, contract action, audit-record IDS findings, and the operational and reputational consequences that exceed the headline penalty number.
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