Tips for a Better CMS Program Audit Experience
August 26, 2025
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.
Advent Advisory Group Insights
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.
Aside from the usual updates to the audit timeline and other wording changes, this year’s HEDIS audit manual includes several changes of significance.
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.
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.
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.
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.
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.
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.
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.
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.
