Advent Advisory Group Insights

NCQA PCO Measures for SNPs: Operational Realities and Considerations for HEDIS MY 2027

Wed, 18 Mar 2026 17:10:26 GMT

Regulatory momentum is building around person-centered outcomes. NCQA’s proposed Person-Centered Outcome (PCO) measures for HEDIS MY 2027 aim to improve the quality of care for Special Needs Plans (SNPs), but operational realities make implementation challenging for many health plans.

Advent Advisory recently submitted public comments expressing concerns about including the proposed PCO measures at this time. While the intent aligns with improving member outcomes, current industry workflows and systems may not yet be equipped to fully support these requirements.

Key Challenges Facing Health Plans

State-Mandated Tools Vary Widely
Many states require plans to use their own assessment and goal-setting forms. These forms often do not include standardized instruments or allow for Goal Attainment Scaling (GAS).
Data Limitations
Information is frequently captured in unstructured fields—or even on paper—making it difficult to collect the specific data elements NCQA proposes.
Workflow and System Gaps
Care management systems are generally not configured to track or report against the new PCO measure specifications. Significant system changes and staff training would be required to comply.
Operational Burden
Plans may be able to meet the intent of the measures but would face a high operational lift to adhere fully to the technical requirements.

Implications for Health Plans

Plans need to carefully assess their current care management workflows and data capabilities.
Incremental process changes and system enhancements may be required before full adoption is feasible.
Staff training and governance around standardized assessments will be critical to ensure compliance and defensibility.

What Plans Should Consider Now

Even before these measures are finalized, proactive steps can help plans prepare:

Evaluate current assessment tools and goal-setting processes.
Identify gaps in structured data capture and reporting capabilities.
Explore hybrid or phased implementation strategies.
Engage advisors to anticipate potential operational and regulatory impacts.

The proposed PCO measures have the potential to significantly enhance member outcomes, but operational readiness is a key barrier for many SNPs. Plans that assess their workflows, systems, and data infrastructure now will be better positioned to adopt these measures in the future.

Advent Advisory can help organizations understand the evolving regulatory landscape and prepare for implementation—ensuring operational readiness while maintaining quality and compliance.

Reach out to our team to discuss how these changes may impact your organization and plan your next steps.

HEDIS® 2026 Public Comment Period: Key Takeaways and Impact Analysis

Thu, 19 Feb 2026 16:36:44 GMT

NCQA has opened the 2026 HEDIS® Public Comment period, running from February 13 through March 13, 2026 .

This annual process provides health plans, purchasers, consumers, and other stakeholders the opportunity to comment on the relevance, scientific validity, and practicality of proposed updates to HEDIS specifications. While participation is not required, it offers organizations the chance to weigh in on changes that may affect reporting, operations, and compliance.

What Is Included in This Year’s Public Comment

NCQA is seeking feedback in three primary areas:

Proposed New Measures
Proposed Changes to Existing Measures
Notification of Changes (items not subject to Public Comment)

These proposals may carry operational, reporting, and audit implications depending on scope and implementation timelines. Early review allows organizations to assess potential impact to systems, documentation workflows, vendor configurations, and quality reporting strategies.

All Public Comment materials and submission instructions are available on NCQA’s Public Comment webpage.

Why This Matters

Although submission of comments is optional, participation allows health plans to:

Share perspective on feasibility and implementation burden
Identify potential operational challenges
Support the advancement of meaningful, practical measurement

How Advent Can Support

As an NCQA-accredited HEDIS Compliance Audit organization and HITRUST-certified firm , Advent provides structured impact analysis and compliance-focused advisory services related to specification updates.

We assist health plans with:

Reviewing proposed measure changes
Assessing operational and documentation impacts
Identifying audit and validation considerations
Supporting Public Comment strategy and submission

Proactive evaluation of proposed changes can help reduce downstream risk and support audit readiness ahead of implementation.

Please let us know if this summary meets your needs or if you would like the information reorganized or additional points emphasized.

CMS Releases CY 2027 Advance Notice: Key Considerations for Medicare Advantage Plans

Fri, 30 Jan 2026 15:42:24 GMT

CMS has released its CY 2027 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. While the proposed updates reflect relative payment stability, they continue to reinforce CMS’s broader priorities around payment accuracy, data integrity, and quality measurement modernization.

Key Takeaways

If finalized, the proposed policies are projected to result in a net average year-over-year payment increase of 0.09%, representing more than $700 million in additional MA payments for CY 2027.

Beyond the topline payment impact, CMS’s proposals signal continued focus in several important areas:

Greater payment accuracy and cost alignment, reinforcing CMS’s efforts to better match payments with beneficiary health status and underlying costs
Ongoing updates to risk adjustment methodology, aimed at reducing administrative burden while refining model accuracy
Star Ratings administrative updates, particularly affecting HEDIS-based measures transitioning to Electronic Clinical Data Systems (ECDS)-only reporting

Star Ratings: Quality Bonus Payment (QBP) Add-On

CMS proposes maintaining the current Quality Bonus Payment (QBP) structure applied to county benchmark rates:

STARS Quality Bonus Payment Percentage add-on to county rates*

New MA plans and low-enrollment plans would continue to receive a 3.5% QBP.

How Advent Advisory Supports Plans

As CMS continues to modernize quality measurement and reporting expectations, Advent Advisory is working closely with health plans to navigate these changes.

For existing Medicare Advantage plans, we support:

Aligning data sources and reporting workflows to fully enable ECDS-based HEDIS reporting
Strengthening data governance and validation processes to support quality performance under evolving requirements

For organizations new to Medicare Advantage, we help:

Interpret reporting and submission requirements
Identify and assess eligible data sources that can support HEDIS ECDS reporting from the outset
Establish scalable reporting frameworks aligned with CMS expectations

Looking Ahead

While the CY 2027 Advance Notice reflects modest payment growth, it underscores CMS’s continued emphasis on data-driven accuracy, quality modernization, and operational readiness. Plans that invest early in aligning data, reporting, and quality infrastructure will be better positioned as these proposed policies move toward finalization.

 Advent Advisory remains committed to helping health plans translate regulatory change into practical, sustainable execution.

Key Action Items for CMS 2026 Program Audit: What You Need to Know

Tue, 25 Nov 2025 19:27:40 GMT

The CMS 2026 Program Audit Annual Updates bring several important changes that healthcare sponsors must address to stay compliant. These updates affect various aspects of the audit process, from condition classifications to new requirements for validation audits.

At Advent , we are committed to helping organizations navigate these changes with confidence. Below, we’ve outlined the key action items from the CMS 2026 updates, along with how Advent’s services can support your compliance efforts.

1. New Condition Classifications

CMS has removed references to audit scoring and point values, introducing new condition classifications and updated corrective action processes. These changes require organizations to adapt their approach to audit findings:

Corrective Action Required (CAR): Prepare to address findings that require correction. CMS expects Sponsor Organizations to prioritize findings that may impact access to services or result in adverse outcomes if left uncorrected.
Observation: Monitor and document noncompliance that doesn’t require a formal corrective action plan but still needs attention.
Invalid Data Submission (IDS): Ensure universe data submissions are accurate and complete.

Advent’s role:

We can help you develop corrective action plans, track progress, and ensure compliance with the updated requirements. Our data management solutions also ensure accurate and complete submissions to prevent issues with IDS.

2. Prepare for the New Compliance Program Effectiveness (CPE) Audit Approach

The new Compliance Program Effectiveness (CPE) Audit approach requires in-depth discussions with CMS about how your compliance program prevents, detects, and corrects noncompliance. CMS expects organizations to demonstrate a comprehensive, proactive compliance program.

Advent’s role:

Collaborating across compliance and program teams, we help identify root causes of noncompliance and ensure corrective actions are taken. We also assist in collecting and organizing Compliance Oversight Activities (COA) universe data for CMS review.

3. Plan for Quarterly Compliance Calls

CMS will continue hosting quarterly educational calls for compliance officers. These calls are an opportunity to learn about common compliance issues, best practices, and share knowledge with industry peers.

Advent’s role:

We recommend assigning compliance officers to participate in these calls. Advent can also assist by helping your team stay updated on the latest CMS developments and preparing them with relevant questions or topics for discussion.

4. Understand Validation Audit Requirements

CMS’s focus on validation audits is critical, particularly for findings that require validation. Simple corrections may only require evidence of correction, such as updated templates, while complex findings may lead to independent validation audits.

Advent’s role:

We can help track which findings require validation audits and prepare the supporting documentation needed. Our team will also help monitor the number of conditions requiring validation to determine if an independent auditor is necessary.

5. Monitor Routine Audit Updates

Be prepared for routine audit engagement letters from CMS between February and August 2026 . Fieldwork periods will last for two weeks, and your organization needs to be ready to coordinate resources accordingly.

Advent’s role:

We can help plan for the audit fieldwork, ensuring that all necessary resources are available and that compliance with Part C coverage and utilization management requirements is met.

6. Utilize CMS Resources

CMS provides helpful resources, including the User Group Resource Document , Audit Submission Checklist , and FA Validation Work Plan Training . Use these resources to stay organized and ensure you meet CMS expectations.

Advent’s role:

We will guide you through these resources and help you address any questions or concerns you have. Additionally, we can assist in preparing for submissions and making sure your organization is audit-ready.

Advent’s Support for CMS 2026 Compliance

The changes to the CMS 2026 Program Audit requirements are significant, but with the right preparation, your organization can stay ahead of the curve. Advent’s comprehensive compliance services are designed to ensure your organization is audit-ready, from corrective action planning to data accuracy and validation.

Let us help you streamline your compliance processes, reduce audit risks, and ensure your success in meeting CMS requirements.

It’s time to start preparing for the CMS 2026 Program Audit.

Review your current compliance strategies and reach out to Advent for guidance. With our support, you can be confident that your organization will be well-positioned for success.

HEDIS MY2025 Audit Changes

Thu, 13 Nov 2025 21:27:59 GMT

Aside from the usual updates to the audit timeline and other wording changes, this year’s HEDIS audit manual includes several changes of significance.

1. Medical record review (MRR) Validation:

If your organization is using technology-driven abstraction processes (e.g., artificial intelligence (AI)) this year, prepare your team for some additional audit requirements.

HEDIS MY2025 Roadmap – Answer the new questions regarding where and how technology is implemented for medical record review abstraction.
MRR System/Process Review – Be prepared to provide a demonstration of any new automated technology used for MRR abstraction.
Program Oversight – Report quality and accuracy standard results for automated abstraction technology separately from manual MRR abstraction.
Convenience Sample Validation – If this is the first year your organization is implementing automated technology for MRR, expect that convenience sample validation will be required.
MRR Hybrid Counts – Ensure your MRR software can identify and report on numerator and exclusion hits from manual-driven and technology-driven abstraction processes separately.
Final Statistical Validation – Be prepared to undergo final validation separately for numerators and exclusions hits from manual-driven v. technology-driven abstraction processes.

2. Supplemental Data Validation:

If your organization is considering including any new supplemental data sources for HEDIS MY2025, be prepared to undergo primary source verification (PSV) for all first-year nonstandard supplemental files, first-year files using the C-CDA or FHIR data standards, and any files where AI or machine learning are involved.

As HEDIS expectations evolve—particularly around AI, technology-driven abstraction, and supplemental data validation—having the right partner matters.

Advent brings hands-on audit expertise to help you prepare, validate, and operationalize these new requirements.

Let’s work together to strengthen your audit readiness for MY2025. Contact Advent to get started.

Key Takeaways from the 2025 NCQA Health Innovation Summit

Tue, 21 Oct 2025 17:53:38 GMT

The Advent team had the opportunity to attend the NCQA Health Innovation Summit , where healthcare leaders and innovators came together to explore the next phase of digital quality measurement and value-based care.

A few themes stood out from this year’s discussions:

1. Digital reporting is a marathon, not a sprint.
The transition to digital quality measurement will unfold over several years. It’s a journey that requires iterative progress, shared learning, and adaptability across the industry.

2. Feedback loops drive data quality.
When working with clinical data submitters, timely and transparent feedback on data errors is critical to resolving issues and improving accuracy at scale.

3. AI can help standardize unstructured data — with the right oversight.

Artificial intelligence shows promise in identifying, extracting, and normalizing unstructured data. However, human review and retraining remain essential to ensure precision and reliability.

4. Interoperability doesn’t solve coding challenges.
Digital connectivity is an enabler — but accurate, consistent coding remains the foundation for effective digital reporting.

At Advent, we’re proud to help organizations bridge the gap between clinical data, quality reporting and operational excellence — supporting a more connected, data-driven future in healthcare.

HEDIS Performance Takes Center Stage as 2026 Medicare Advantage Star Ratings Hold Steady

Thu, 16 Oct 2025 16:19:50 GMT

HEDIS is shifting. Stars are flattening. Advantage goes to plans that act now.

After several consecutive years of declines, the average Medicare Advantage (MA) Star Ratings are essentially flat for 2026. Similar to last year, approximately 40% of contracts earned at least 4 stars —the threshold for quality bonus payments.

While overall stability may seem encouraging, there are notable shifts at the plan and measure level , particularly among HEDIS-reported measures that continue to drive overall Star performance.

Key Highlights:

High Performers See Modest Growth
CMS identified 21 plans as “high performing” for 2026, up from 13 in 2025 . Of these, 18 achieved a full 5-Star Rating. The increase signals targeted improvement among select organizations, though many others experienced rating declines amid heightened measure-level volatility.

Most HEDIS Measures Improved—With a Few Key Exceptions
Overall, most HEDIS measures posted rate increases year-over-year. However, two measures— Colorectal Cancer Screening and Plan All-Cause Readmissions —declined, likely reflecting recent changes to technical specifications and reporting criteria.

Five Measures Fell Below 3 Stars
These low-performing areas indicate continued opportunities for improvement, especially across three HEDIS measures:
Osteoporosis Management in Women Who Had a Fracture
Plan All-Cause Readmissions
Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions

Seven Measures Exceeded 4 Stars
Among the top-performing measures, only one HEDIS indicator— Care for Older Adults: Medication Review —surpassed the 4-Star threshold. This measure continues to demo.

Hybrid HEDIS Indicators Trending Up Ahead
All five hybrid HEDIS indicators slated for inclusion in the 2027 Star Ratings cycle increased in rate, suggesting that plans are already preparing for the upcoming retirement of hybrid methodology and strengthening data workflows.
Care for Older Adults – Medication Review: +1.42 ppt
Eye Exam for Patients with Diabetes: +2.42 ppt
Glycemic Status Assessment for Patients with Diabetes: +1.68 ppt
Controlling High Blood Pressure: +2.69 ppt
Transitions of Care: +4.29 ppt

Notably, Medication Reconciliation Post-Discharge and Care for Older Adults – Pain Assessment will be removed from Star Ratings beginning next year.

Part C and D Measures Also Shifted: Both the MTM Program Completion Rate for CMR and Special Needs Plan (SNP) Care Management measures showed rate increases. While MTMP is being removed from Star Ratings for now (display-only in 2025–2026), it will return in 2027 as a new measure —plans should begin preparing to ensure robust performance.

Looking Ahead: The New Reality for Star Performance

CMS projects a decline in total quality bonus payments across Medicare Advantage. As Star thresholds tighten and volatility persists, maintaining a 4-Star rating may become the exception rather than the rule. Plans that previously earned bonuses at 4 Stars may now find themselves at risk of slipping below that line.

HEDIS measures remain the most actionable lever for improving overall Star Ratings. Plans that focus now on closing measure gaps , enhancing supplemental data governance and strengthening quality oversight will be best positioned to weather the evolving measurement environment.

Ready to turn HEDIS data into results?
Advent helps Medicare Advantage plans identify their greatest opportunities, operationalize measure improvement and build strategies that deliver lasting Star gains. Schedule a HEDIS Readiness Consultation with Advent today.

Adopting a year-round, data-driven approach, with a continued focus on quality improvement, is key to HEDIS success.”

— Jean Vertefeuille, CEO, Advent Advisory Group

Advent partners with plans to operationalize quality improvement — bridging data, compliance, and clinical workflows to drive measurable HEDIS and Star gains.

2025 California Association of Health Plans (CAHP) Annual Conference

Fri, 10 Oct 2025 20:44:10 GMT

For the first time, Advent Advisory Group attended the 2025 California Association of Health Plans (CAHP) Annual Conference which convened over 1,000 healthcare leaders, policymakers, and innovators to address the evolving landscape of managed care in California. Central themes included regulatory updates, innovations in care delivery, and strategies to improve access, affordability, and health outcomes. A major focus was the anticipated impact of H.R.1, the One Big Beautiful Bill Act (OBBBA), which poses significant challenges across all sectors of California’s health insurance ecosystem.

Medicare Advantage (MA):

Stricter eligibility rules may disenfranchise many lawfully present immigrants.
Increased costs for low-income beneficiaries due to changes in:
Medicare Savings Programs (MSPs)
Low-Income Subsidy (LIS)
Higher out-of-pocket costs for dual-eligible individuals under Medicare Part D.
Estimated 4% reduction in provider payments.
Limited drug coverage, including exclusion of orphan drugs.
Reduction or elimination of supplemental benefits (e.g., dental, vision, hearing aids, gym memberships).
Potential withdrawal of some insurers from the MA market.

Why Ratings Matter:

Up to $30 billion in federal funding at risk.
Coverage loss projected for approximately 3.4 million Medi-Cal members.
New work requirements and eligibility restrictions may further limit access.

Covered California (Exchange Market):

Enhanced federal tax credits set to expire on December 31, 2025.
Projected 10.3% premium increase in 2026.
Financial impact by income level:
Individuals earning <$40,000: premiums may double.
Families earning >$62,000: premiums may increase by over $500/month.
Family of four earning >$129,000: premium will increase by over $750/month.

Commercial Market:

Expanded Health Savings Account (HSA) eligibility for bronze and catastrophic plans.
Permanent pre-deductible coverage for telehealth services.
Formal recognition of Direct Primary Care (DPC) arrangements as HSA-compatible.

As California leaders assess the sweeping implications of these proposed changes, Advent Advisory Group is helping health plans evaluate exposure, model financial impacts, and prepare operational strategies across Medicare, Medi-Cal, and Commercial lines.

Connect with us to discuss how your organization can navigate policy uncertainty and position for stability heading into 2026.

Turning NCQA 2025 Health Plan Ratings into a Roadmap for Improvement

Fri, 19 Sep 2025 17:07:05 GMT

The 2025 NCQA Health Plan Ratings are out. For health plans, these results are more than just numbers — they’re a public reflection of quality, experience, and performance.

This year’s ratings highlight progress, new measures that raise the bar, and sharper contrasts between top performers and those falling behind. The challenge is clear: ratings are not only a benchmark; they’re a competitive differentiator.

At Advent Advisory Group , an NCQA-licensed organization , we help plans make sense of their results, identify opportunities, and implement changes that drive measurable gains.

What's New in 2025:

Language Diversity of Membership (LDM): Plans must now report on members’ preferred spoken and written languages.

CAHPS still critical: Member experience remains a top driver of ratings.

Chronic condition gains: Improvements in diabetes management and care transitions.

Coordination matters: Smooth transitions remain a differentiator — gaps still exist.

Why Ratings Matter

High NCQA ratings build trust with members , competitive positioning , and credibility with regulators and purchasers . Accreditation also earns bonus points, directly boosting scores.

Common Struggles

Reporting readiness: Many plans aren’t fully prepared for reporting of descriptive measures, like LDM and Race/Ethnicity Diversity of Membership (RDM)

Gaps in data: Sunsetting of the hybrid methodology presents new data challenges

CAHPS performance: Member experience continues to drag down ratings.

Inconsistent results: Strong in one area, weak in others — uneven performance.

The Bottom Line

As Betsy Seals, CEO of Alerion Advisors, recently noted: “Transparency and accuracy are now key differentiators in the Medicare Advantage market.”

Humana borrows UnitedHealth’s Medicare Advantage playbook - Modern Healthcare

At Advent, we don’t just react to ratings — we help you get ahead. Let’s turn your NCQA into a blueprint for stronger quality, compliance, and growth.

How Advent Helps

With NCQA licensing and deep HEDIS audit expertise, Advent provides:

Compliance audit support to validate measures and correct discrepancies.

Gap analysis across metrics impacting ratings.

Support for new measures , from data to process.

Benchmarking and competitive insight for market positioning.

Learn more about Advent’s HEDIS Audit Services ›

Tips for a Better CMS Program Audit Experience

Tue, 26 Aug 2025 15:42:08 GMT

CMS recently published its annual Part C and Part D Program Audit and Enforcement Report. The report provided recommendations and guidance for Sponsors to consider when preparing for future CMS Program Audits.

Key tips include:

1: Undergo a Mock CMS Program Audit — Identify vulnerabilities, spot noncompliance, and prepare staff.

2: Validate Data Universes — Ensure submissions are accurate, complete, and compliant with CMS record layouts.

3: Ensure Access to HPMS — Verify contact info, confirm staff access, and prepare to use the HPMS audit module for data transfers.

4: Confirm Technology Readiness — Test Microsoft Teams access, screen-sharing, and delegate readiness in advance.

5: Establish a Quality Review Process — Use checklists and automated tools to ensure documentation and data accuracy.

These recommendations aim to streamline the audit process, reduce compliance risks, and improve sponsor performance.

Stay Audit-Ready with Advent

Preparing for a CMS Program Audit doesn’t have to be overwhelming. At Advent Advisory Group, we help health plans turn CMS guidance into actionable strategies that reduce risk and build confidence.

Our experts partner with your team to deliver:

✅ CMS Program Audit Universe Assessments
✅ Mock Audit Review Services
✅ Expert Compliance Consulting
✅ Independent Auditor Validation Support

With Advent, you can move from audit anxiety to proactive assurance — ensuring your plan is ready, compliant, and confident when CMS comes calling.

Contact our team today:

Erin Hudd

ehudd@adventadvisorygroup.com

Edite Carvalho-Kane ecarvalhokane@adventadvisorygroup.com

Optimizing Clinical Data Quality for HEDIS Reporting

Thu, 07 Aug 2025 18:40:01 GMT

Advent’s HEDIS 2026 webinar series kicked off last month with Optimizing Clinical Data Quality, a presentation focused on common challenges with supplemental clinical data.

Key takeaways include the following:

Transition in Data Collection: The shift from manual data collection to digital HEDIS reporting has increased the focus on clinical data over claims data. NCQA’s planned elimination of the hybrid reporting method has added urgency to this transition, driving plans to acquire more electronic clinical data and adapt to year-round ingestion.

Challenges with Clinical Data: The presentation highlighted several challenges to the acquisition of supplemental clinical data, including data timing, completeness, and accuracy. Issues such as short turnaround times, missing biometric values, and incorrect coding have impacted the useability of these additional data sources for HEDIS reporting.

Tips for Navigating the Transition: Plans can navigate this transition by starting early with clinical data validation, engaging with IT departments, exploring vendor’s reports and supportive capabilities, and building executive leadership buy-in.

For more tips on validating supplemental clinical data sources, contact our HEDIS department at: info@adventadvisorygroup.com

Medicare Part C & Part D Data Validation Audits: Lessons Learned

Thu, 10 Jul 2025 14:42:46 GMT

Another year of Medicare Part C and Part D Data Validation (DV) audits is in the books. Here are a few key takeaways and best practices from this year’s experience:

1. Share CMS Technical Specifications Early

Ensure all report owners receive CMS technical specs and reporting requirements well in advance. This promotes clear understanding of required data elements and ensures alignment for HPMS submissions and audit readiness.

2. Strengthen Internal Quality Control

A robust internal QC process is essential. Assign a lead to manage this effort and establish standardized checks. Block time in March to confirm that what’s submitted in HPMS accurately reflects your intended data.

3. Validate Vendor Data Throughout the Year

Accurate reporting hinges on reliable vendor data. Set expectations for vendors with delegated reporting responsibilities to provide both summary and detailed data. Request clear references or documentation to interpret results effectively.

4. Create a Centralized Measure Reporting Library

Maintain a central repository that includes final submissions (HPMS summary and supporting detail), measure logic, and relevant policies and procedures. These documents not only support measure reporting but also fulfill many DV audit documentation requirements.

Congratulations to our Medicare clients on another successful reporting year. As always, early preparation and strong processes are the foundation of accurate reporting and DV audit success.

Advent is here to help—our team is uniquely equipped to support your Medicare Part C and D reporting needs.

Learn more: Medicare Part C And Part D Data Validation Pre-Assessment

HEDIS MY2025 Considerations

Wed, 18 Jun 2025 20:04:12 GMT

With the ink barely dry on HEDIS MY2024, planning for HEDIS MY2025 is already underway. Advent’s HEDIS webinar series will start up soon. In the meantime, here are some changes to keep in mind.

1. Medical record review option eliminated for 4 longtime hybrid measures.

Childhood Immunization Status (CIS)
Immunizations for Adolescents (IMA)
Cervical Cancer Screening (CCS)
Eye Exam for Patients with Diabetes (EED)

2. New data element – Breast Imaging Reporting and Data System (BI-RADS) assessment codes – needed for the 2 new mammogram-related measures. BI-RADS-related value sets include SNOMED CT codes as well as RadLex radiology lexicon. RadLex is a comprehensive set of radiology terms for how medical imaging is described, reported, and analyzed.

3. Change in race and ethnicity data source reporting requirements.

Reporting on the source of race and ethnicity data will only be required for the Race/Ethnicity Diversity of Membership (RDM) measure. Race and ethnicity stratifications (RES) will still be required for other measures; however, the source of that data will not be reported at the measure-level.

Data source reporting for RDM has been condensed to the following 4 categories.

Direct: Race/ethnicity value is known, and the source is direct (e.g., self-reported, CMS and state data sources).
Imputed: Race/ethnicity value is known but is collected through an alternate data source (e.g., geo-coding, surname analysis).
Unknown: Race/ethnicity value is known but the source is not.
No Data: Race/ethnicity value is not known.

As always, when in doubt check in with your auditor. They can provide more insights into these and other changes for HEDIS MY2025. And remember, the earlier you get started, the better prepared you will be.

Contact us at info@adventadvisorygroup.com to see how we can help.

Update on NCQA’s Move to Digital Quality Measures for HEDIS Reporting

Mon, 05 May 2025 20:38:40 GMT

Earlier this month, Advent met with NCQA to confirm their plan to provide the HEDIS measure specifications in a digital format. Key takeaways from the meeting are outlined below.

NCQA’s Digital Content Services use FHIR® data only. Users must secure data in or convert data to a FHIR format to execute NCQA’s digital quality measures (dQMs).

A parallel testing plan will be implemented to compare measures produced using traditional certified measure code to those executed using NCQA’s digital measure packages.

Plans may elect to use NCQA’s Digital Content Services directly. However, they will likely still need a vendor, or internal resources, for other reporting functions, including producing patient-level detail files and XMLs for loading the IDSS as well as medical record review tools.

As measure certified vendors move to using NCQA’s digital packages for their measure logic, measure certification will change to dQM Implementation Validation. The dQM Implementation Validation program will confirm “correct execution of the digital content in the organization's environment” to ensure the digital quality measures execute as expected.

NCQA plans to move to a fully digital state by MY 2030. This aligns with their goal to completely phase out the hybrid method by MY 2029.

For more information, check out NCQA’s recent webinar on Digital Quality Transition Update: May 2025 - NCQA .

FHIR® is a registered trademark of Health Level Seven International and its use does not constitute endorsement by HL 7.

Contact us at info@adventadvisorygroup.com to see how we can help.

Ensuring CMS Audit Readiness

Mon, 07 Apr 2025 20:27:36 GMT

Advent recently hosted a webinar focused on helping Medicare plans prepare for a CMS Program Audit. With critical updates shared by our experts, our goal was to ensure organizations feel confident heading into the audit season. Here are five key takeaways you need to know:

1. CMS Engagement Letters Sent Between April and July 2025

Health plans selected for a CMS Program Audit will receive their engagement letters between April and July 2025. If you make it to August or September without receiving a letter, you're likely in the clear for this cycle. But preparation shouldn’t begin when the letter arrives—readiness starts now.

Pro Tip: Advent offers pre-audit support, including mock engagement reviews and

universe readiness assessments to get ahead of the curve. We also offer a self-service universe scrubber for validation of internal and/or vendor universes.

2. CMS Fieldwork is Now Condensed into a Two-Week Period

CMS has consolidated fieldwork into a structured two-week window:

Week 1: Review of operational program areas
Week 2: Compliance Program Effectiveness (CPE) review

This change emphasizes the need for timely, organized, and well-documented case files, grievance records, call notes, and communications.

How Advent Helps: Our mock audits mimic this structure, helping plans prepare under realistic timelines and expectations.

3. Universe Submission Requires Speed and Accuracy

After receiving the audit letter, organizations have just 15 business days to submit their universe tables. Within five days of the universe submission, CMS will conduct integrity testing by reviewing samples from each submitted table to ensure data validity and consistency. Errors in inter-field logic, case documentation, or data integrity can lead to findings.

Advent’s Advantage: Our CMS Program Audit Universe Assessment scrubs your

universes across ODAG, CDAG, CPE, SNP, MMPCC, FA, SARAG, and UM—highlighting

issues before CMS finds them.

4. Some Tables Are Suspended for 2025—But Not Retired

CMS has suspended data collection for the following tables:

FA Table 3: Prescription Drug Event (PDE)
CDAG Table 7: Comprehensive Addiction and Recovery Act (CARA) At-Risk Determination (AR)
ODAG Table 6: Dual Special Needs Plan – Applicable Integrated Plan Reductions, Suspensions, and Terminations (AIP)

Pro Tip: While not retired, these tables are on hold for this cycle. It's essential to maintain internal tracking and audit processes, as they could return in future cycles.

5. A New Audit Protocol for Part C Utilization Management Begins in 2026

Starting in 2026, CMS will implement a new audit protocol focused on Part C Utilization Management. Plans will need to:

Report internal coverage criteria for CMS targeted services
Identify entities or vendors involved in developing internal criteria
Provide links to coverage policies
Submit an annual data report by January 31 each year

This new reporting requirement underscores CMS’ emphasis on transparency,

consistency, and accountability in clinical decision-making.

Advent Insight: We guide plans in preparing for this shift—reviewing internal

policies, developing data collection frameworks, and ensuring compliance. Advent

will have a universe scrubber to align with new UM protocols once finalized by CMS.

Stay Ahead with Advent’s Services

Our mission is to help health plans meet CMS expectations with confidence and clarity, turning audit anxiety into proactive assurance.

We offer comprehensive services to support your audit readiness:

CMS Program Audit Universe Assessments
Mock Audit Review Services
Expert Compliance Consulting
Independent Auditor Validation Support

Contact us at:

Erin Hudd
ehudd@adventadvisorygroup.com

Edite Carvalho-Kane ecarvalhokane@adventadvisorygroup.com

Key Takeaways for the URAC 2024 Performance Measurement Reports

Tue, 04 Mar 2025 20:17:32 GMT

URAC recently released its 2024 performance reports ( Performance Measurement Results - URAC ) for specialty pharmacies, mail service pharmacies, and pharmacy benefit management (PBM) organizations.

Key takeaways include the following:

99.9+% of prescriptions are filled with no dispensing or distribution errors.
When a dispensing error occurred, it was most likely due to incorrect quantity.
When a distribution error occurred, it was most likely delivered to the wrong location despite having the correct patient address.
On average, mail service pharmacies fill prescriptions within 1.93 days and specialty pharmacies within 6.01 days.
For mail order pharmacies and PBMs, 97+% of prescriptions are dispensed as generics, branded generics or brands for which members paid a generic co-pay.

Performance measurement for the 2024 reporting year aligns with Phase 2 of URAC’s measurement process where mandatory performance measures are subject to an external data validation process.

With the URAC 2025 reporting cycle starting soon, there is still time to identify areas of opportunity for improvement and ensure ongoing compliance with program standards for this or next year.

Questions? Contact us at info@adventadvisorygroup.com and we will connect you with one of our URAC performance measure specialists.

Is your provider organization demonstrating high-value care?

Mon, 03 Feb 2025 20:08:39 GMT

Demonstrating quality of care starts in the providers’ office and ends in the data warehouse. Limited data can provide an incomplete picture of the care that is being provided.

Provider organizations throughout the country struggle with securing the data needed to accurately measure their performance. Very often health plans and providers generate different results for the same population even when they are working from the same set of standards and using the same methodologies.

This has been demonstrated year after year in California, even though the Integrated Healthcare Association’s (IHA) Align. Measure. Perform. (AMP) program relies on a “common set of performance measures.” With IHA’s new value-based incentive design methodology ( AMP Incentive Design - Integrated Healthcare Association ) it is even more important that provider organizations report the highest rates possible to ensure accurate alignment with financial rewards.

Provider organizations that act now, during the measurement year, will be best positioned to reap the benefits for next year’s reporting.

Contact us at info@adventadvisorygroup.com to see how we can help.

A Compelling Case for Building Confidence in Data

Mon, 06 Jan 2025 19:25:38 GMT

Data validation ensures clinical registry data are consistent, accurate, and complete, and that the data conform to business rules so that insights gained from the data are based on meaningful information and can confidently be used for downstream purposes such as population health analytics, business intelligence, and training machine learning models.

Given the ever-increasing number and complexity of clinical data sources, in-house teams, despite their expertise, may face challenges in accurately evaluating the validity of the data due to competing priorities and resource limitations. Independent validation provided by third-party experts adds a layer of objective assessment to the data validation process and ensures data validation standards and practices are rigorously adhered to. It can also identify issues that internal teams may miss.

The return on investment can be viewed in terms of both cost savings and streamlining processes. Through third-party validation and implementing improvements, clinical registries can realize increased efficiency and improved decision making, as well as stakeholder confidence.

Advent Advisory Group Insights

NCQA PCO Measures for SNPs: Operational Realities and Considerations for HEDIS MY 2027

Key Challenges Facing Health Plans

Implications for Health Plans

What Plans Should Consider Now

HEDIS® 2026 Public Comment Period: Key Takeaways and Impact Analysis

What Is Included in This Year’s Public Comment

Why This Matters

How Advent Can Support

CMS Releases CY 2027 Advance Notice: Key Considerations for Medicare Advantage Plans

Key Takeaways

Star Ratings: Quality Bonus Payment (QBP) Add-On

How Advent Advisory Supports Plans

Looking Ahead

Key Action Items for CMS 2026 Program Audit: What You Need to Know

1. New Condition Classifications

Advent’s role:

2. Prepare for the New Compliance Program Effectiveness (CPE) Audit Approach

Advent’s role:

3. Plan for Quarterly Compliance Calls

Advent’s role:

4. Understand Validation Audit Requirements

Advent’s role:

5. Monitor Routine Audit Updates

Advent’s role:

6. Utilize CMS Resources

Advent’s role:

Advent’s Support for CMS 2026 Compliance

It’s time to start preparing for the CMS 2026 Program Audit.

HEDIS MY2025 Audit Changes

1. Medical record review (MRR) Validation:

2. Supplemental Data Validation:

Advent brings hands-on audit expertise to help you prepare, validate, and operationalize these new requirements.

Let’s work together to strengthen your audit readiness for MY2025. Contact Advent to get started.

Key Takeaways from the 2025 NCQA Health Innovation Summit

At Advent, we’re proud to help organizations bridge the gap between clinical data, quality reporting and operational excellence — supporting a more connected, data-driven future in healthcare.

HEDIS Performance Takes Center Stage as 2026 Medicare Advantage Star Ratings Hold Steady

Key Highlights:

Looking Ahead: The New Reality for Star Performance

Adopting a year-round, data-driven approach, with a continued focus on quality improvement, is key to HEDIS success.”

— Jean Vertefeuille, CEO, Advent Advisory Group

﻿ Advent partners with plans to operationalize quality improvement — bridging data, compliance, and clinical workflows to drive measurable HEDIS and Star gains.

2025 California Association of Health Plans (CAHP) Annual Conference

Medicare Advantage (MA):

Why Ratings Matter:

Covered California (Exchange Market):

Commercial Market: ﻿

As California leaders assess the sweeping implications of these proposed changes, Advent Advisory Group is helping health plans evaluate exposure, model financial impacts, and prepare operational strategies across Medicare, Medi-Cal, and Commercial lines.

Connect with us to discuss how your organization can navigate policy uncertainty and position for stability heading into 2026.

Turning NCQA 2025 Health Plan Ratings into a Roadmap for Improvement

What's New in 2025:

Why Ratings Matter

Common Struggles

The Bottom Line

How Advent Helps

Tips for a Better CMS Program Audit Experience

Key tips include:

﻿

Stay Audit-Ready with Advent

Contact our team today:

Optimizing Clinical Data Quality for HEDIS Reporting

Key takeaways include the following:

For more tips on validating supplemental clinical data sources, contact our HEDIS department at: info@adventadvisorygroup.com ﻿

Medicare Part C & Part D Data Validation Audits: Lessons Learned

Advent is here to help—our team is uniquely equipped to support your Medicare Part C and D reporting needs.

Learn more: Medicare Part C And Part D Data Validation Pre-Assessment

HEDIS MY2025 Considerations

As always, when in doubt check in with your auditor. They can provide more insights into these and other changes for HEDIS MY2025. And remember, the earlier you get started, the better prepared you will be.

Contact us at info@adventadvisorygroup.com to see how we can help.

Update on NCQA’s Move to Digital Quality Measures for HEDIS Reporting

Contact us at info@adventadvisorygroup.com to see how we can help.

Ensuring CMS Audit Readiness

1. CMS Engagement Letters Sent Between April and July 2025

2. CMS Fieldwork is Now Condensed into a Two-Week Period

3. Universe Submission Requires Speed and Accuracy

4. Some Tables Are Suspended for 2025—But Not Retired

5. A New Audit Protocol for Part C Utilization Management Begins in 2026

Stay Ahead with Advent’s Services

Contact us at:

Erin Hudd ehudd@adventadvisorygroup.com

Advent partners with plans to operationalize quality improvement — bridging data, compliance, and clinical workflows to drive measurable HEDIS and Star gains.

Commercial Market:

For more tips on validating supplemental clinical data sources, contact our HEDIS department at: info@adventadvisorygroup.com

Erin Hudd
ehudd@adventadvisorygroup.com