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.

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.

HEDIS MY2025 Considerations

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.

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.

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.

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.