CMS Program Audit Readiness: What Health Plans Must Know in 2026

CMS will begin issuing Program Audit notifications next month, and health plans should be actively preparing now—not waiting for the audit letter to arrive. The most audit-ready plans aren’t scrambling; they’ve already done the hard work. This year’s audit landscape reflects CMS’s updated approach to Program Audits, including enhancements to Compliance Program Effectiveness (CPE) reviews, continued operational scrutiny, and evolving data collection expectations.

What proactive audit readiness looks like in practice:

• A formal audit workplan that clearly identifies:

  • All potential audit program areas

  • Required universe tables

  • Data sources and systems of record

  • Accountable owners for data pulls, validation, and submission

    
    

• Universe QA well before an audit notice

  • Reconciliation back to source systems

  • Sampling to confirm data integrity and logic

  • Documentation of known limitations and remediation actions

    
    

• Mock audits and webinar simulations

  • End-to-end walkthroughs that mirror CMS methodology

  • Testing not just documentation, but how teams explain processes and oversight

  • Identification of gaps in Compliance oversight, not just operations

    
    

• Clear ownership and governance

  • Defined roles across Compliance, Operations, IT, and delegated entities

  • Escalation paths for issues identified during preparation

  • Evidence that issues are identified, tracked, and corrected

    
    

• Delegated entity and FDR readiness

  • Validation that downstream entities can support universe development

  • Alignment between plan-level oversight and operational reality

    
    

• CPE-specific preparation aligned to the latest CMS guidance

  • Focused documentation demonstrating how Compliance Program Effectiveness is assessed, measured, and improved — not just described

  • Root cause and impact analyses that allow plans to contextualize noncompliance trends across operations (as recently updated in CMS protocol expectations)

Awareness of CMS data collection changes is also critical

• Some table collections (e.g., FA 3, CDAG 7, ODAG 6) have been suspended in Program Audits, shifting audit emphasis and preparation focus

• Independent auditor validation may be required when multiple unrelated conditions are tested during a validation audit

• Too often, plans discover universe issues, unclear ownership, or process gaps after the audit notice—when timelines are tight and CMS expectations are unforgiving.

At Rebellis Group, we help Medicare Advantage organizations move from reactive to ready by:

• Building audit workplans aligned to current CMS expectations

• Stress-testing universes and data integrity

• Conducting realistic mock audits and tracer prep

• Helping Compliance demonstrate meaningful oversight—not just policy presence

If your plan could receive an audit notice anytime between now and August, the time to call in expert support is now.

Contact us