March 2025
CMS Program Audits continue to evolve, with new focus areas and sharper expectations for plan sponsors. If you're managing Medicare Advantage or Part D operations, staying ahead of these changes is essential.
CMS is using data analytics, complaints, and past performance to select audit targets. Plans with high CTM volumes or unresolved issues are more likely to be audited.
Expect deeper scrutiny of your delegated entities. CMS wants documented evidence of oversight, training, and corrective actions for all FDRs.
CMS isn’t just checking for CAPs—they’re measuring how long it takes you to fix problems. Speed and effectiveness matter more than ever.
For new products or expansions, CMS may initiate readiness reviews sooner. Being able to show policies, procedures, and team preparedness is key.
From trainings to CAPs to internal audits—CMS expects detailed, consistent records. A centralized system can help avoid scrambling when the auditors come knocking.