CMS Audits Are Increasing: Operational Readiness Matters More Than Ever

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.

Across multiple CMS audit findings, several themes emerge:

• Configuration-driven cost sharing errors: Plans applied incorrect copayments or coinsurance due to misaligned benefit setup, fee schedules, or claim editing logic; resulting in members being overcharged.

• Inadequate MOOP tracking and accumulator logic: Failures to accurately track and reconcile member cost accumulation led to members exceeding regulatory limits.

• Fragmented data flows and delegation gaps: Weekly or delayed data exchanges with delegated entities created blind spots where claims continued to apply cost sharing after MOOP thresholds were met.

• System limitations and integration failures: Disconnected accumulators, incorrect rate loading, and claims adjudication timing issues resulted in inconsistent and non-compliant outcomes.

• Delayed detection and remediation: In many cases, issues persisted for years and were only corrected post-audit, increasing financial exposure and member impact.

The takeaway is clear: these are not isolated compliance gaps.  They are operational design challenges across claims platforms, benefit configuration, and financial controls.

How Rebellis supports health plans

Our consulting approach is designed to proactively address these risks before they surface in an audit:

End-to-end claims configuration process validation

We assess benefit setup, fee schedules, and adjudication logic methodology against CMS-approved bid parameters to ensure configuration receives accurate cost sharing for claim processing.

MOOP accumulator integrity and reconciliation

We evaluate accumulator design, data integration, and real-time tracking capabilities, ensuring the plan has processes in place so that all member cost sharing is captured, synchronized, and capped appropriately.

Claims cost share reviews

We review targeted samples across high-risk services to identify where system logic diverges from regulatory requirements or filed benefits.

Delegation and data flow alignment

We validate data exchange timing, frequency, and reconciliation processes between plans and delegated entities to eliminate gaps in MOOP tracking.

Control framework and audit readiness

We implement monitoring controls, reporting, and governance structures aligned to CMS audit expectations, so issues are identified and resolved before they escalate.

Don’t be caught unaware

CMS has made it clear that inaccuracies in cost sharing and MOOP are viewed as failures to meet core contractual obligations, not just technical errors. These issues directly impact members and carry significant financial and reputational consequences.

Health plans that invest in configuration accuracy, system integration, and proactive validation will be far better positioned, not only to pass CMS One Third Financial Audits, but to build resilient, compliant operations at scale.

If you're evaluating your readiness or have concerns about exposure in these areas, now is the time to act.

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