August 28 was an important day for Medicare Advantage Risk Adjustment Data Validation (RADV). CMS officially initiated the Payment Year (PY) 2024 RADV audits, notified the Medicare Advantage organizations selected for audit, and released the PY2024 Audit Methods & Instructions and list of audited contracts.

C-SNPs are Medicare Advantage plans designed specifically for individuals with certain severe or disabling chronic conditions. This gives health plans an opportunity to create a more targeted experience by aligning benefits, clinical programs, pharmacy strategies, provider networks, and member engagement around the needs of a defined population.

New Medicare Advantage and Part D Enrollment and Disenrollment Guidance for CY 2027 and appendices and exhibits released. Make sure you are ready for changes for 1/1/2027 applicants and applications.

Prior authorization (PA) has traditionally been viewed as a clinical function, but the most effective health plans recognize that it is an enterprise-wide capability requiring collaboration across Clinical, Quality, Operations, Compliance, Finance, and Risk Adjustment.

Benefit administration testing continues to be a valuable tool to validate the accuracy of your Medicare Part D pharmacy claims benefit. Part D sponsors are responsible for ensuring their Part D prescription drug coverage is adjudicating consistent with their approved plan design. Benefit administration testing ensures your health plan’s formulary is processing formulary medications accurately and applying correct cost-sharing.

When people think about ACA risk adjustment, they often think first about coding, diagnoses, and risk scores. Those pieces matter, but they are only part of the story.

While CMS positions many of the revisions as reducing administrative burden, the proposal also reflects a more standardized and operationally focused audit methodology that places greater emphasis on stronger operational controls, cleaner data, and more consistent audit processes.

As Medicare Advantage (MA) organizations increasingly adopt artificial intelligence (AI) for utilization management, risk adjustment, claims processing, prior authorization, and other critical functions, a key compliance question arises: Does this AI vendor qualify as a First Tier, Downstream, or Related Entity (FDR)?

CMS is launching the Medicare GLP-1 Bridge on July 1, 2026, creating a new opportunity for certain Medicare beneficiaries to access select GLP-1 medications for weight management that is otherwise not covered through Part D. While the demonstration operates outside of the Medicare Part D coverage and payment flow, health plans still have important operational responsibilities to manage.

CMS' new Medicare GLP-1 Bridge Demonstration Program is generating significant attention for expanding beneficiary access to weight management medications. While the program operates outside of the traditional Medicare Part D benefit, health plans should not assume they can take a hands-off approach.

The Office of Inspector General (OIG) recently released a report estimating that CMS may have overpaid Medicare Advantage Organizations approximately $462 million in 2021 based on unsupported acute stroke diagnoses. For those working in Medicare Advantage risk adjustment, the findings themselves should not come as a surprise.

Clover Care’s lawsuit against HHS raises a question that goes well beyond a technical dispute over measures: are Medicare Star Ratings simply a mirror that reflects performance, or have they become a steering wheel that directs the system itself?

The 2027 Marketplace Final Rule includes expanded marketing and broker oversight and enrollment integrity scrutiny. Marketing materials that include misleading “zero-dollar” plan references or misrepresented enrollment deadlines, for example, are in CMS’s crosshairs.

The Centers for Medicare & Medicaid Services (CMS) recently released its 2027 ACA Notice of Benefit and Payment Parameters Final Rule, introducing significant changes aimed at reducing costs, strengthening program integrity, cracking down on fraud, and increasing state flexibility across ACA Exchanges.

In just the past few weeks, several AI companies reached out to our compliance practice for support in building formal compliance programs. Both were responding to health plan RFPs. Both were being asked essentially the same question: “Do you meet our FDR compliance requirements?”

Health plans are under increasing scrutiny as CMS intensifies its focus on financial integrity, particularly through One Third Financial Audits. Recent enforcement actions highlight a consistent pattern: issues with cost sharing accuracy and maximum out-of-pocket (MOOP) compliance are not isolated events, but systemic risks embedded within claims processing and configuration even among well-established health plans.

Alerion Advisors today announced the appointment of Jason Montrie as Chief Executive Officer, marking a pivotal milestone in the company’s evolution as a leading integrated platform for health plans, providers and service partners.

Two recent CMS enforcement actions highlight a key compliance risk: operational breakdowns in Part D and PACE programs. Here’s what organizations need to know to stay audit-ready

For health plans and marketing teams, material development is constant—but compliant review and approval is where delays happen. From ANOCs and EOCs to sales materials, websites, and physician communications, every piece must meet CMS, state, and ACA requirements before it can go live. Without the right structure and expertise, review cycles become slow, fragmented, and prone to rework.