Under the Microscope: CMS Tightens Initial Determinations and Appeals Oversight

CMS is signaling closer scrutiny of initial organization determinations and appeals reconsiderations in Medicare Advantage Part C.

In May, CMS released draft technical specs for Service Level Data Collection, followed by an HPMS memo in June. The new requirements reflect a shift from broad metrics to granular, linked reporting that ties directly to ODAG audit universes.

What’s Changing?
• Separate reporting for services vs. claims
• Closer alignment with ODAG protocols
• Tighter link between each step in review and CMS guidance
• More complexity—and more compliance risk

Key Challenges for Plans & FDRs
• Competing priorities and resource constraints
• Retooling systems, policies and training
• Limited time to validate data and implement changes
• First-time accuracy matters: resubmissions raise red flags

Read on for full article here, including revised 30-day tech specs compared to current ODAG program audit protocols

Why the CMS Part C/D Audit Cycle Matters More Than Ever 

In the past three years, CMS has quietly, steadily — and now unmistakably — cranked up oversight of Medicare Advantage and Part D plans. And the 2024 audit cycle? It’s broader, sharper, and more pointed than ever.

Whether you’re a seasoned Medicare leader or a compliance newcomer, this year’s CMS Part C & D Program Audit and Enforcement Report reads less like an annual recap and more like a roadmap for the future of managed care oversight.

After two years of auditing smaller sponsors, CMS returned to broad market coverage in 2024, and it wasn’t subtle:

• CMS increased the number of parent organizations audited from 25 in 2022 and 2023 to 36 in 2024, with 39 total audits conducted

• 2024 audits impacted nearly 88% of the Medicare Advantage population, a sharp rise from 63% in 2023

• 494 contracts were reviewed in 2024—nearly six times more than in 2023

Here’s what we’re watching

Podcast | Connecting Quality, Compliance and Population Health in Managed Care

In the HEALTHCARE STARcast, host Subbu Ramalingam breaks down the complex world of healthcare to reveal the real strategies and mindsets driving excellence. In this clip, Subbu and Charles Baker, VP of Compliance Solutions at ATTAC Consulting Group, dig into the realities of compliance, quality improvement, Medicare Advantage pressures, and the evolving landscape of risk adjustment and RADV audits. You’ll hear actionable insights for health plan leaders and providers, a no-nonsense approach to regulatory changes, and practical ideas for bridging the gaps between compliance, operations, and patient care.

Tune in to hear expert insights on Medicare Advantage RADV, and what steps health plans should take now to prepare for the biggest audit expansion in CMS history.