Why Data Visibility is Key to Maintaining Compliance as a Medicare Advantage Health Plan

June 16, 2020 – ZeOmega

Medicare Advantage (MA) health plans are governed by a complex and stringent set of regulations designed to protect consumers and ensure the delivery of high-quality care.
These administrative and clinical guidelines are often highly detailed and extremely time sensitive. From completing utilization management decisions to addressing appeals and grievances, health plans must execute certain actions within specific time frames so that members can receive the right care to meet their needs.

The Centers for Medicare and Medicaid Services (CMS) has made it very clear that failing to stay in compliance with Medicare Advantage regulations can have serious impacts on health plan sponsors. The consequences for poor performance include financial penalties, lower Star Ratings, and changes to rebate percentages, risk adjustments, and marketing guidelines. Since CMS audit findings are publicly available, the ratings and audit results may impact member enrollment and re-enrollment decisions.

Proactive management of the compliance components included in audits will be the key to passing the review with flying colors. MA plans that start strong and stay committed to streamlined, automated, and well-documented compliance strategies will put themselves in the best position to generate internal efficiencies and create positive member experiences, both of which will be reflected in their audit results.

Yet MA plans often find it challenging to complete their processes on time and in an organized manner. Some organizations still rely on manual workflows while others must navigate through disparate data management systems to find information and communicate with colleagues.
In this installment of our series on the top five challenges facing Medicare Advantage plans, we explore how MA plans can overcome these compliance issues by leveraging unified, integrated data management platforms to deliver exceptional service to members.

Capturing and managing complete, accurate data in a timely manner

Data management and data governance are incredibly important for MA plans. Health plans receive data from a multitude of sources, including claims systems, pharmacy systems, care management systems, state and federal data feeds, and information from members themselves. But many plans are unable to bring those datasets together in a comprehensive, actionable way to make determinations within the prescribed timeframes.

Working with disparate data management platforms creates a patchwork of information and convoluted, manual workarounds. Staff members must spend extra time and effort logging in and out of multiple systems and may struggle to accurately track the provenance or status of key data elements.

Some health plans still use emails, Excel spreadsheets, or even paper systems to track case statuses, which can create bottlenecks and worrisome gaps in communication. As a result, decisions may be delayed, opportunities could be missed – and health plans can easily fall out of compliance.

A single platform that can integrate multiple data sources into a holistic view of a member’s needs can improve staff productivity, support better communication, and ensure staff members are completing tasks according to CMS requirements.

Leveraging dashboards to prioritize tasks and improve productivity

To remain in compliance, MA health plans need to know when they are at risk of missing deadlines and how to prioritize time-sensitive events. When data is scattered across multiple systems or housed in tools that cannot calculate or manage timed tasks, health plans are largely unable to identify which items are at risk of being overdue.

Easy-to-understand dashboards backed by a comprehensive data management platform enable staff to quickly and easily view the status of a case and flag items that need immediate attention. Users can access alerts that guide decision making around high-priority tasks, reassign those tasks to the next person responsible for the case, and keep workflows moving at an appropriate pace.

Technology that allows MA plans to prioritize workflows should also support increased automation of critical compliance tasks. For example, using timestamps, automated rules, and user actions as triggers, a compliance management platform can automatically guide the plan through a compliant workflow, such as sending required notifications to members or their representatives within the right timeframes.

This ensures that plans deliver high-quality member experiences while also reducing the effort required to generate, customize, and send notifications, allowing plans to reallocate valuable staffing resources to the at-risk population.

Managers and health plan executives can use this wealth of information to benchmark productivity, monitor caseloads, predict compliance trends, and identify opportunities to improve. By enhancing visibility into the compliance process, teams can work more effectively together while pinpointing issues that can have a negative impact on turnaround times.

Staying one step ahead of potential audits

Each year, CMS selects a subset of MA plans for auditing. While COVID-19 has changed the audit program for 2020, the typical selection process is random, so MA plans need to be prepared at all times to prove they are meeting their compliance obligations. A strong, cohesive health IT infrastructure is the starting point for success.

MA health plans need to be able to generate the required reports with the correct information whenever they are asked to do so and for self-auditing throughout the year. They must also be certain that they are pulling the right data elements into those reports every single time. Every second matters when it comes to staying in compliance with tight turnaround windows, so using accurate timestamps and recording every step of a process in precise detail is crucial for ensuring a smooth CMS audit.


Using health IT tools to automate these tasks as much as possible can ease the burden on health plans, helping them feel comfortable about meeting their compliance goals. With actionable insights into critical data and the ability to prioritize, share, and analyze information in a single platform, MA plans can tackle the challenges of compliance while improving productivity and offering quality service to their members. Building upon this strong foundation will prepare plans for the many challenges and opportunities of operating in the thriving Medicare Advantage marketplace.

Coming up next

In our next blog post, we will discuss the challenges of Medicare Advantage audits in more detail and discuss effective strategies for demonstrating compliance during an assessment and avoiding the potential penalties of falling short.

Want to dive deeper into these five challenges and their solutions? Read the rest of the Top 5 MA Challenges blog series: