87. 2024 Medicare Advantage and Part D Program Audit Enforcement Report Out: What Does It Tell Us?
Release Date: 08/08/2025
87. 2024 Medicare Advantage and Part D Program Audit Enforcement Report Out: What Does It Tell Us?
The Healthcare Labyrinth
CMS’ Medicare Advantage (MA) program audits are getting tougher and more detailed every year. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American...
info_outline
86. Will The New 100% RADV Audits Be Fair To Medicare Advantage Plans?
The Healthcare Labyrinth
While justified, there is some question about whether the new RADV audits will be fair to MA plans. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American...
info_outline
85. Healthcare Developments Beyond The One Big Beautiful Bill
The Healthcare Labyrinth
The Big Beautiful Bill buried some other important healthcare developments. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help...
info_outline
84. The One Big Beautiful Bill Passes
The Healthcare Labyrinth
The one big beautiful bill has passed. Listen in to learn about how it happened and the impact of healthcare reductions. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and...
info_outline
83. Are There Smarter Healthcare Cuts?
The Healthcare Labyrinth
There are smarter healthcare cuts and sensible reforms that could be made and spare major impacts to coverage. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in...
info_outline
82. Will Health Plan Pain Continue?
The Healthcare Labyrinth
As bad as health plans have had it the past few years, trends seem to show the pain continuing. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American...
info_outline
81. How Mighty Big Healthcare Has Fallen
The Healthcare Labyrinth
The mighty big healthcare companies have fallen, in this case a victim of their own financial mismanagement and shenanigans. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues...
info_outline
80. Republicans Are In Stealth Mode On Healthcare Coverage Cuts, But The Impact Is Real
The Healthcare Labyrinth
The GOP is not following the same overt repeal of healthcare coverage as it did in 2017, but the stealth approach still has real impact. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most...
info_outline
79. Managed Care Enters New Cycle; Medicare Advantage Needs To Pivot To Thrive
The Healthcare Labyrinth
Managed care is entering a new conversion cycle just as Medicare Advantage plans have to pivot to thrive. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American...
info_outline
78. The Budget Reconciliation Saga
The Healthcare Labyrinth
The House has passed the budget reconciliation bill, but the Senate intends to put its mark on the bill and there are competing forces as in the House. Final passage is some time off still. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast...
info_outlineCMS’ Medicare Advantage (MA) program audits are getting tougher and more detailed every year.
About The Podcast:
Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.
Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.
Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.
Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.
Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.
Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.
About The Episode:
On this episode, Marc discusses Medicare Advantage compliance. CMS’ program audits are getting tougher and more detailed every year.
Key Takeaways:
Overall, CMS’ program audit protocols are fair and reasonable. They hold plans accountable for the delivery of care to Medicare beneficiaries.
There are four core audit protocols and a fifth for Special Needs Plans.
The 2023 and 2024 program audit report shows MA audits are getting tougher and more detailed.
Compliance Program Effectiveness is closely being scrutinized due to concerns about oversight of delegated vendors.
Formulary Administration is also an active area due to concerns on correct prior auth edits, claims configuration, cost-sharing, and transition fills.
Scrutiny of medical service and drug authorizations and appeals remain very detailed, with clinicians digging deep into cases and determination of medical necessity.
On Special Needs Plans, CMS is always concerned about health risk assessments but is now going beyond that to determining if care plans are addressing all of the identified needs of individuals.
CMS says plans are implementing and carrying out the new utilization management rules, but scrutiny should increase in the future.
Financial audits are also increasingly rigorous and focused on no beneficiary harm.
Record civil monetary penalties were levied in 2024.
Connect with Marc:
Resources:
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance