Coffee Chat: CMS Program Audits in 2026—Key Changes and What Medicare Health Plans Should Do Now

CMS program audits don’t just test compliance. They test bandwidth. They test documentation. They test whether your operations team can keep the lights on while leadership is pulled into audit webinars, case reviews, universe submissions, and remediation plans.

In other words: audits aren’t just a regulatory exercise—they’re an organizational stress test.

That’s why we recently sat down for a coffee chat with Karen Mason, a Medicare compliance and operations expert from BluePeak Advisors, to unpack what’s changing in CMS program audits for 2026 (and what’s already being proposed for 2027).

And while the conversation covered a lot—scoring changes, compliance oversight shifts, new focus areas—one theme kept showing up again and again:

Audit season creates a staffing crunch… even for high-performing plans.

What Is a CMS Program Audit? (MA and Part D Overview)

Karen explained that CMS program audits are conducted annually and typically run from late winter through the end of summer. For 2026, CMS has announced the audit season will likely run from February through August and as many as 30 plans are expected to be chosen.

The audits focus on several core areas, including:

• Formulary and Benefit Administration (Part D)
• Coverage Determinations, Appeals, and Grievances (Part D)
• Organization Determinations, Appeals, and Grievances (Part C)
• Special Needs Plan (SNP) Care Coordination
• And new this year, incorporating compliance effectiveness in each program area as opposed to a separate area.

And while the audit itself may be scheduled for a certain window, the process can stretch for 12+ months depending on findings, corrective actions, and validation audits.

Translation for those that have never been through an audit: it’s rarely “quick.”

CMS Program Audit Changes in 2026: Scoring Updates and New Audit Classifications

CMS is making some major shifts to audit structure and scoring in 2026.

One of the biggest? The scoring system is going away.

Previously, plans were assigned points based on findings (lower = better). CMS is eliminating that approach altogether.

CMS is also simplifying how audit findings are classified. Instead of multiple buckets, findings will now generally fall into two categories:

• Observation
• Corrective Action Required (CAR)

Karen described this as a smart move—less ambiguity, fewer debates between auditors and plans, and a clearer process overall. But she also cautioned against a dangerous assumption:

No score doesn’t mean less accountability.

Plans will still be required to fix issues. Timelines will still be tight. And operational disruption will still be real.

2026 CMS Compliance Oversight Changes: CPE Integration Into Operational Audit Areas

Historically, compliance had its own audit lane: Compliance Program Effectiveness (CPE).

But in 2026, CMS is changing that model.

Instead of auditing compliance separately, compliance teams will now be evaluated inside each program area audit. That means compliance leaders will be sitting in audit webinars alongside operations leaders during reviews of appeals, grievances, coverage decisions, and care coordination.

And CMS will ask questions in real time like:

• “Did compliance know this was happening?”
• “Was this issue documented in your oversight universe?”
• “What did you do about it?”

Karen emphasized that this shift puts pressure on both sides:

• Operations teams must be transparent with compliance
• Compliance teams must deeply understand what CMS is looking for in each program area

Because if compliance and operations are misaligned, CMS will spot it immediately.

How Staffing Shortages Impact CMS Audit Outcomes

During the chat, Karen was asked where staffing shortages create the biggest audit risk.

Her answer: timeliness.

When plans don’t have enough staff to manage volume, the first breakdown is usually turnaround times—especially in high-pressure workflows like:

• Urgent Part D requests (some with 24-hour requirements)
• Appeals and grievance resolution timelines
• Case management outreach and documentation requirements

CMS doesn’t just review a handful of cases. They review timeliness across the entire universe of submissions.

So, when staffing is tight, even small delays can quickly become a visible pattern.

Medical Record Retrieval and Case File Preparation During CMS Program Audits

One of the most operationally stressful parts of a program audit is what happens after CMS selects the cases they want to review.

Plans are given limited time to pull everything needed to support those case files, including:

• Medical records
• Decision history
• Member communications
• Clinical reviewer documentation
• Timestamps and evidence of process compliance

Karen noted that prepping these case files is extremely time-consuming and often becomes a scramble, especially for lean teams or organizations with complex care models like SNPs.

It’s a heavy lift even in a normal week. During audit season? It becomes a sprint.

CMS Audit Resource Burden: How Program Audits Disrupt Health Plan Operations

Karen referenced CMS estimates that program audits take 300–346 hours on average.

But that estimate doesn’t capture the real-world impact: audit season pulls critical leaders out of daily operations. Medical directors, compliance leaders, department VPs, and operations managers often spend significant time preparing for and participating in audit activities.

Meanwhile, member needs and day-to-day operations don’t slow down.

That’s where pressure builds—and where organizations often feel the need to add support quickly.

CMS Audit Readiness Checklist: How Health Plans Can Prepare for 2026 Audits

When it comes to actual audit readiness, Karen highlighted several proactive strategies that help health plans prepare before CMS audit notices arrive:

• Reviewing universes monthly or quarterly
• Validating data integrity early
• Running mock audits
• Reviewing member communications (especially denial letters)
• Strengthening vendor oversight (PBMs, care management partners, and other FDRs)
• Training teams on audit expectations and documentation discipline

These aren’t just abstract suggestions—they’re the kinds of practical steps many plans are already building into their 2026 readiness playbooks.

For a more structured, step-by-step guide, you can follow the CMS Medicare Advantage Audit Preparation Checklist developed by Medix. This checklist outlines critical readiness items that compliance, operations, risk, and audit teams should consider as they prepare for expanded CMS scrutiny—from documentation best practices to timeline planning and risk validation workflows.

What This Means for Health Plans Heading Into Audit Season

If there’s one takeaway Karen made crystal clear, it’s this: CMS audits don’t just evaluate compliance, they expose operational strain.

Even well-run organizations can find themselves scrambling when timelines tighten, documentation requests pile up, and key leaders are pulled into audit prep meetings and webinars. And when that happens, the cracks tend to show up in predictable places: timeliness, case documentation, record retrieval, and cross-team coordination.

That’s why audit readiness often requires two things working together:

1. Audit Expertise

BluePeak Advisors help health plans interpret audit expectations, run mock audits, identify risk areas early, and guide remediation when findings occur.

2. Execution Capacity

Because preparation is only half the battle—plans also need enough staff to keep workflows moving while audit activity ramps up. That’s where Medix can support organizations with experienced talent across key operational areas like appeals and grievances, care coordination, utilization management support, member outreach, and documentation-heavy audit prep work.

In short: audit season demands both strategy and staffing. And the organizations that handle it best are the ones that plan for both.

Key Takeaways: CMS Program Audits Require Both Compliance and Operational Capacity

Karen’s insights reinforced something we see across the healthcare landscape:

CMS audits are becoming more operationally complex, more integrated across departments, and more focused on the member experience.

And while organizations can prepare with better processes and stronger oversight, audit season still demands one thing above all: enough people to execute.

Because compliance doesn’t happen in theory. It happens in inboxes, case queues, phone calls, documentation trails, and turnaround times. And during audit season, that work has to happen fast.

Don’t delay—connect with Medix today to ramp up the support your teams need to stay compliant, stay efficient, and stay ready.