Audit readiness assessment for healthcare payers
Audits are no longer the finish line for health plans. They are only the symptom check. The real work sits deeper, inside the quality of your data, the consistency of your processes, and the accuracy of what your systems produce every day. When a plan becomes data ready, audit readiness becomes a byproduct. This assessment helps you understand where you truly stand.
Why audit readiness alone is no longer enough
Audit preparation has historically been episodic. Every year, teams rush to assemble files, scrub universes, reconcile discrepancies, and chase down vendors. This cycle is reactive, expensive, and fragile.
CMS is tightening expectations across Medicare Advantage, Part D, Medicaid managed care, and delegated programs. The shift is clear. Plans that succeed are not the ones who prepare for audits, but the ones who maintain data hygiene throughout the year.
Being data ready means:
- clean, validated, and reconciled data across systems
- clear lineage and ownership of universe, case, and operational data
- audit files that can be produced any day, not just during a CMS cycle
- stronger operational oversight and lower compliance risk
- resilience during audits, CMS inquiries, FOIAs, and CAP validations
This assessment measures how far your plan is from that model.
What this assessment measures
This is not a checklist of audit tasks.
It evaluates your end-to-end data readiness maturity, covering:
Data hygiene and accuracy
- Universe data integrity
- Field-level accuracy
- Date consistency, TAT accuracy, N/A logic
- Duplicate, missing, or misaligned records
Source system alignment
- Case management system
- Appeals & grievances systems
- Delegated vendor data
- Enrollment and claims systems
- Reporting and analytics layers
Operational readiness
- Documentation and SOP currency
- CMS model alignment
- Intake-to-resolution traceability
- Governance and escalation pathways
Cross-functional collaboration
- Compliance, Ops, IT, Delegation, Vendor Management participation
- Completeness of submissions
- Real-time monitoring and exception reporting
Readiness for CMS audits & validations
- Universe generation capability
- Scrubbing and validation rigor
- Ability to self-identify issues
- CAP follow-through maturity
Your output: a defensible, data-ready scorecard
At the end of the assessment, you receive a score across five components:
- Data hygiene
- System alignment
- Operational readiness
- Governance and documentation
- Cross-functional resilience
Each score maps to one of three maturity levels:
- Foundational readiness — reactive, audit-specific; fragile under scrutiny
- Emerging readiness — pockets of strength; inconsistent data alignment
- Data-ready maturity — capable of defending audit outcomes anytime
This gives your teams a clear view of where to focus effort.
Why data readiness is a continuous and defensible strategy
Only Audit readiness is temporary.
Data readiness is structural and systemic.
Plans that invest in data readiness to augment their audit readiness, benefit from:
- fewer late-cycle scrambles
- higher accuracy and lower audit risk
- stronger vendor oversight
- predictable CMS interactions
- operational intelligence across functions
- real-time error detection
- improved member experience
- defensible positions during audits and CAP reviews
Data-ready plans do not “prepare” for audits.
They simply run the report.
Who should take this assessment
This assessment is designed for leaders and teams responsible for maintaining audit-ready and data-ready operations across a health plan. It is most useful for:
Compliance leaders
Chief Compliance Officers, Directors, Managers.
They need a clear view of how well the plan can withstand CMS scrutiny without last-minute remediation.
Audit teams
Internal auditors, CMS audit leads, and delegated oversight teams.
They want to benchmark readiness and identify where operational and data gaps introduce audit risk.
Operations leaders
A&G leaders, Member Services leaders, Intake and Case Management owners.
They need to understand whether upstream data and processes support clean downstream reporting.
IT and data teams
Enterprise data managers, system owners, analytics leads.
They want to assess data hygiene, lineage, and system alignment that impact universe accuracy.
Delegation and vendor oversight teams
Oversight and reporting leads working with FDRs and delegated entities.
They need visibility into how well external data aligns with CMS expectations and internal systems.
Executive leadership
COO, CIO, VP of Operations.
They look for structural weaknesses that affect audit outcomes, member experience, and operational efficiency.
Take the assessment
This takes less than 8 minutes.
No sensitive data is required or stored by us.
Your score and insights are generated instantly and shared over email.
Audit readiness assessment for healthcare payers
From being just audit-ready to being data-ready
Audits are no longer the finish line for health plans. They are only the symptom check. The real work sits deeper, inside the quality of your data, the consistency of your processes, and the accuracy of what your systems produce every day. When a plan becomes data ready, audit readiness becomes a byproduct. This assessment helps you understand where you truly stand. Plans that succeed are not the ones who prepare for audits, but the ones who maintain data hygiene throughout the year.
This assessment measures how far your plan is from that model.
What this assessment measures
This is not a checklist of audit tasks. It evaluates your end-to-end data readiness maturity.
- Evaluate your readiness across critical audit areas.
- Get instant results and address gaps.
- Ensure compliance and avoid penalties.
- Use your score to improve.