CMS’ recent audit report is well thought out and offers plans excellent advice in an increasingly complex compliance environment.
About The Podcast:
Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.
Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.
Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.
Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.
Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.
Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America.
About The Episode:
In this episode, Marc discusses CMS’ recent audit report. It is well thought out and offers plans excellent advice in an increasingly complex compliance environment.
Key Takeaways:
When I first started dealing with this stuff, CMS oversight could sometimes feel inconsistent. Standards weren’t always as well developed. Enforcement could be uneven.
That has changed. CMS has built a much more sophisticated audit and enforcement machine. And the compliance bar is moving upward.
The 2025 program audit and enforcement report gives excellent advice for performing well in a complex compliance environment.
It is no longer good enough to have policies – execution is essential.
Much of non-compliance is tied to operational deficiencies across the plan enterprise.
Plans also do not make decisions based on complete information – even when it is available.
Vendor oversight is lacking and vendors fail to execute on plan requirements. They need better oversight.
Ongoing internal audits, disclosure, and transparency with CMS could be the difference. CMS wants you to find your own problems.
Prior authorization reforms and CMS’ use of AI could up the stakes on compliance.
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Resources:
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
