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Why the first MA-guidance in decades signals a new era of scrutiny and execution.
On February 3rd, the Office of the Inspector General (OIG) released a Medicare Advantage Industry Segment-Specific Compliance Program Guidance. This marks the first time since 1999 that the OIG has issued formal, MA-specific guidance outlining its compliance expectations for Medicare Advantage plans.
This guidance clarifies OIG’s priorities and reinforces a clear message: compliance must be fully embedded into day-to-day operations. The document emphasizes strong governance, efficient and documented workflows, accountability across first-tier, downstream entities and proactive risk identification and management.
The OIG identified several areas that warrant focused and sustained attention, including:
- Access to Care (Network Adequacy and Prior Authorization)
- Marketing and Enrollment
- Risk Adjustment
- Quality of Care (Stars)
- Oversight of Third Parties
- Compliance Programs Within Vertically Integrated Organizations and Other Ownership Structures
- Submission of Accurate Claims
Why this Matters: Reinforced and Sustained Scrutiny
Medicare Advantage has been under increasing scrutiny for several years and this guidance reinforces that heightened oversight is not temporary. Recent actions by Centers for Medicare & Medicare Services (CMS), including expansion of RADV audits to all MA contracts, updated compliance protocols and a growing number of lawsuits addressing fraudulent or non-compliant behavior, signal a sustained regulatory focus on program integrity.
What Should Plans Do Now
Plans should view the OIG’s MA Compliance Guidance as a roadmap for strengthening compliance and operational risk by:
- Assessing organizational strengths and gaps to identify and prioritize key compliance and operational risks
- Establishing strong governance and accountability across all internal, delegated and downstream entities
- Implementing targeted risk assessments, auditing and monitoring to proactively identify, mitigate and manage compliance risks
- Aligning compliance strategy with quality outcomes and enterprise-wide risk management through an actionable, ongoing compliance plan
