CMS Just Named Delegation Oversight a Top Audit Finding. Is Your Plan Ready?
CMS’s 2024 Program Audit Report explicitly flagged FDR oversight failures as a recurring deficiency across Medicare Advantage plans. With CMS […]
Your A&G Intake Bottleneck Is Costing You Good Staff and CMS Timeliness Compliance — All at the Same Time
Appeals and grievances volumes are rising across Medicare Advantage. Staff who process them are burning out and leaving. CMS is
The Health Plan Compliance Leader’s Guide to Evaluating Delegation Oversight Platforms
Generic FDR oversight software were not built for CMS FDR requirements. Here’s how to evaluate delegation oversight platforms on the
Grievance Misclassification Is CMS’s Most Recurring ODAG Finding. It Starts at Intake.
CMS auditors don’t just test timeliness — they test whether your plan correctly identified what it received in the first
Medicare Advantage compliance is becoming operational surveillance
OIG’s Medicare Advantage compliance guidance points to a shift from process verification to operational surveillance. Health plans are increasingly expected to monitor trends continuously, detect behavioral patterns across denials, appeals, delegated oversight, and data quality, and demonstrate awareness of emerging risk before it becomes an audit issue.
The Cost of Compliance Variability in Healthcare Payer Operations
Compliance failures rarely begin with misconduct. They begin with variability. In healthcare payer operations, compliance risk rarely shows up as
A&G Automation Doesn’t Replace Governance, It Enforces It in Health Plan
In payer operations, Appeals & Grievances is where policy meets reality. A&G automation governance is becoming an essential aspect of
Why Data Scrubbing Is the Missing Layer in Delegation Audit Defensibility
Why delegation audit defensibility is now a leadership issue Delegation audit defensibility used to be a compliance team concern. Today,
Why A&G timeliness failures repeat, and why CMS considers them systemic
Appeals and Grievances timeliness failures rarely happen because teams do not understand the rules. Most payer organizations know the timelines,
How to Standardize Delegate Data Submissions for CMS Program AuditsÂ
For health plans, CMS audits do not begin with documentation. They begin with data. To ensure accuracy, it’s often beneficial