Overview

Recent enforcement actions from the Centers for Medicare & Medicaid Services (CMS) reinforce a clear and consistent message: compliance risk is driven by how operations perform—not just how policies are written.

From Part D transition failures to care coordination gaps, CMS continues to cite organizations for breakdowns in execution—often tied to data, workflows, and oversight.

For Medicare Advantage plans, this raises an important question: How confident are you in your data before CMS sees it?

The Risk: Finding Issues After Submission

Many organizations still take a reactive approach:

• Submit data to CMS
• Identify issues after the fact

But as recent enforcement actions show, errors are not just operational—they are regulatory risks.

Common challenges include:

• Incomplete or inconsistent data across systems
• Gaps in documentation or coding
• Misalignment between clinical activity and reported data
• Limited visibility into data quality before submission

The result?

• Missed revenue opportunities
• Lower Star Ratings
• Increased audit and enforcement exposure

What CMS Enforcement Is Telling Us

Recent CMS CMPs highlight a consistent theme: small operational and data breakdowns can lead to measurable consequences.

Whether it’s:

• Incorrect system logic impacting pharmacy claims
• Failure to execute care decisions
• Gaps in tracking and follow-through

These issues share a common root: lack of visibility into performance before it reaches CMS.

A Shift Toward Pre-Assessment

Leading plans are shifting to a more proactive model: validating data before submission.

Pre-assessment provides:

• Early insight into data quality and accuracy
• Targeted sampling to identify high-risk gaps
• Time to correct issues before CMS review
• Greater confidence in submission outcomes

This is not about reviewing everything—it’s about identifying what matters most, early enough to act.

Why Timing Matters

Pre-assessment efforts typically begin in the fall, with planning happening now.

Plans that delay:

• Lose the opportunity to correct issues
• Operate with incomplete visibility
• Increase downstream compliance and financial risk

The most successful organizations treat pre-assessment as a core part of their compliance strategy—not a last-minute check.

From Compliance to Confidence

CMS is continuing to move toward:

• Greater transparency
• Real-time visibility into performance
• Stronger alignment between operations and reported data

This means the question is no longer: “Are we compliant?”

It’s: “Will our data hold up under CMS scrutiny?”

How Advent Can Help

Advent supports Medicare Advantage plans with targeted pre-assessment and data validation services, helping organizations:

• Identify high-impact data and documentation gaps
• Align operational workflows with reporting requirements
• Reduce audit and enforcement risk
• Improve financial and quality outcomes