Coming out of the HCCA Compliance Conference this week, one thing is clear—compliance and regulatory oversight are evolving rapidly. Health plans must stay ahead of heightened scrutiny in Utilization Management (UM), Prior Authorization, and Third-Party Marketing Organization (TPMO) regulations. With CMS providing limited guidance, now is the time to stay proactive and maintain robust compliance programs.
Key Compliance Takeaways from HCCA:
🔹 Regulatory Timeline for 2026: If CMS doesn’t announce major updates soon, changes won’t impact Plan Year 2026—but plans must still be ready for potential shifts.
🔹 Increased Oversight on TPMOs: Health plans must ensure vendors supporting sales and marketing have the infrastructure, compliance programs, and oversight needed to meet regulatory expectations.
🔹 Surge in Regulatory RFI Requests: Plans are seeing multiple, complex data requests from federal and state agencies—each with different objectives. A one-size-fits-all approach won’t work—data must align with specific requests.
🔹 UM & Program Audits Under the Microscope: CMS auditors are closely reviewing UM policies, prior authorization processes, and cross-functional compliance gaps—real-time oversight is critical.
🔹 AI in Healthcare: Growing Compliance Risks: AI-driven prior authorization and claims processing require human oversight to maintain accuracy and avoid legal and ethical concerns.
How Rebellis Group Can Help
At Rebellis Group, we help health plans:
✔ Strengthen UM and Prior Authorization compliance to meet audit expectations
✔ Ensure TPMO vendors align with regulatory and contractual requirements
✔ Develop proactive strategies for managing regulatory RFI requests
✔ Navigate AI-driven compliance challenges with expert oversight.
We also offer a subscription service that analyzes HPMS regulatory memos and proposed and final rules, keeping your team informed of the latest updates to support compliance and operational success.
With increasing regulatory scrutiny, now is the time to reinforce your compliance strategy and stay ahead of CMS expectations.
Let’s discuss how Rebellis Group can support your plan.
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