Prior Authorization Metrics and Your ODAG Universes: Are They Telling the Same Story?
By March 31, 2026, Medicare Advantage organizations were required to post their first public prior authorization metrics: approval and denial
Why Monitoring Delegated Entities and Vendors on a Single Platform Is Becoming a Compliance Imperative
A health plan’s regulated work often reaches well beyond its own walls. A pharmacy benefit manager (PBM) processes Part D
How Health Plans Build Multi-Channel A&G Intake That Holds Up Under CMS Timeliness Rules
In Medicare Advantage, a standard organization determination is due within 7 calendar days for services subject to prior authorization and
How Health Plans Manage CMS Corrective Action Plans
From audit finding to verified closure. CMS no longer scores findings, and a validation audit does not measure whether a
How to Build, Scrub and Clear ODAG and CDAG Universes Before Submission
Universes are not supporting documentation. They are the population a CMS program audit samples from — which is why a
Two regulators, one ops bench: why dual-LOB A&GÂ deadlines slip
Plans running both a D-SNP and a state Medicaid managed care line work two regulatory regimes on one intake queue.
What CMS Sees in Your CTM Data Before You Do
Every complaint that reaches the CMS Complaints Tracking Module is logged, categorized, and on the clock before your plan hears
CMS’s Proposed 2027 Medicare Advantage Program Audit Protocols: What Compliance Officers Need to Know
On July 6, 2026, CMS published a Federal Register notice (document 2026-13603) seeking OMB approval for a revised information collection
Keeping Up With Regulatory Change Across States Without a War Room
The challenge is not adherence; most plans respond. It is whether the response is documented with a defensible evidence trail,
Continuous Internal Audit for MA Plans: What Year-Round Readiness Actually Requires
CMS no longer audits in seasons. With compliance now embedded in every program area and reviews running year-round, audit readiness
The 5 pillars of a continuous audit readiness framework for health plans
A continuous audit readiness framework is not a technology purchase, a new team structure, or an expanded budget. It is
Mock audits for health plans: why once a year is not enough
A mock audit for a health plan should work as a diagnostic tool — not a final exam. Yet in
