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.

CMS released the PY2020 Medicare Advantage RADV audit notices on Friday—and this round is significant. A total of 471 Medicare Advantage contracts are now under review, making it the largest audit cohort to date.

CMS recently released an updated Risk Adjustment Data Validation (RADV) Questions & Answers document along with a schedule outlining when upcoming Medicare Advantage RADV audits are expected to begin by payment year. While the release does not introduce major policy changes, it does provide something many organizations have been looking for, which is greater transparency into how CMS intends to sequence future RADV audits.

CMS is introducing a major shift in how Medicare approaches obesity and metabolic health through the Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) Model.

Regional health plans are navigating intense pressure right now — medical cost containment, CMS scrutiny, growth targets, member experience expectations, and operational resilience. And yet, many plans are operating under a quiet assumption: “Our call center partner is fine.” Maybe they are. But here’s the better question: If you were selecting your call center vendor today — knowing what you now know about performance, compliance risk, scalability, and cost — would you make

CMS has released portions of the February 2026 Medicare Advantage enrollment files. While membership by individual plan and plan/county has not yet been published, parent organization-level enrollment data (excluding PDP) provides early insight into market movement following a year of plan exits and regulatory pressure.