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On June 9th, CMS published a draft of new regulatory reporting requirements that enhance oversight of initial organization determinations (ODs) and reconsiderations. This follows the direction set in the 2026 Medicare Advantage Final Rule, which introduced regulations to reinforce prior authorization and utilization management (UM) safeguards. The proposed reporting requirements strengthen CMS’s commitment to taking meaningful action to control inappropriate prior authorization and UM practices that create unnecessary barriers to care access. This new administration has made it abundantly clear that wasteful spend, fraud, abuse and inefficiency will not be tolerated.
Reporting Requirement Details
These new reporting requirements will require plans to submit significantly more detailed information on a quarterly basis than what is currently required by CMS, moving from the existing aggregate reporting of cumulative totals and outcome categories (fully favorable, dismissed, adverse, etc.) to comprehensive details on every individual organizational determination and reconsideration they receive.
Actions for Medicare Advantage Plans
These new requirements could cause operational and compliance challenges for Medicare Advantage plans. The granular requirements will provide CMS with a new level of visibility into plan decision-making processes to identify inappropriate denials, processing delays and inconsistent application of coverage criteria. Given this enhanced level of oversight, it's essential that plans develop robust capabilities to produce the required reporting elements accurately and on time, with plans maintaining high denial rates likely facing intensified regulatory scrutiny.
To prepare for these requirements, plans should:
- Review Internal Documentation: Conduct a review of current policies and procedures to ensure that they capture OD and reconsideration compliance requirements
- Establish Quality Validations: Create monitoring processes to track key metrics such as processing timelines and outcomes, denial and adverse decision rates and validity to curb any issues that would raise concern to CMS
- Evaluate Reporting Capabilities: Ensure your OD and reconsideration systems and infrastructure are capable of capturing, storing and reporting detailed case-level data
- Produce Test Reporting: Generating example/test reports sooner rather than later will help plans achieve accuracy in reporting details to ensure CMS timelines are met for report submission requirements and level of accuracy needed
Plans that proactively address these operational and regulatory changes now will be better positioned to demonstrate compliant utilization management practices and avoid potential regulatory consequences such as corrective action plans and financial penalties.
How ProspHire Can Help
Do you need support navigating these new regulatory requirements? ProspHire can help with a comprehensive compliance readiness review to ensure your organization is prepared. Let's have a conversation.
