Let’s have a conversation
1. What Are the New CMS Reporting Requirements?
CMS is expanding oversight of utilization management (UM) programs to ensure health plans deliver timely, appropriate, and high-quality care. Plans must now submit detailed reports on how they implement UM policies, track denials, appeals and decisions, and monitor clinical and operational outcomes.
2. Why Is This Important for Health Plans?
These requirements are about more than compliance—they impact member experience, clinical quality, and financial performance. Staying ahead of these reporting expectations reduces the risk of penalties, supports transparent operations, and strengthens trust with regulators and members alike.
3. How Will These Reporting Changes Affect Daily Operations?
Health plans may see increased workload in areas such as:
- Collecting and analyzing UM data
- Tracking and documenting denials and appeals
- Monitoring adherence to clinical guidelines
- Demonstrating compliance across all lines of business
4. What Challenges Might Health Plans Face in Adapting to These Requirements?
Many organizations struggle with:
- Fragmented data sources
- Limited integration between UM systems and reporting tools
- Ensuring consistent documentation across teams and regions
- Translating regulatory guidance into actionable operational workflows
5. How Can ProspHire Help Health Plans Respond Effectively?
ProspHire partners with health plans to:
- Assess readiness for CMS reporting and UM oversight
- Streamline data collection and reporting processes
- Optimize operational workflows to ensure compliance
- Provide actionable insights to improve UM program performance and member outcomes
6. What's the Bottom Line for CMS?
CMS’s new reporting requirements are a signal that transparent, efficient, and clinically sound utilization management is critical. With the right strategy, processes, and support, health plans can meet regulatory expectations, reduce risk and improve care delivery—turning compliance into a competitive advantage.
