Member service representatives are the heart of a health plan. Their engagement with members significantly influences a member’s perceived experience with the plan and their care journey. For a Medicare Advantage plan the stakes are high. Helping Medicare members navigate an often confusing health system and ensuring they are maximizing their benefits and health outcomes is serious business, and CMS is watching at every turn.
During the 2025 program audit season BluePeak Advisors observed an increased focus on call center activities. Specifically, First Call Resolution (FCR) grievances and Quality of Care (QOC) grievances. These grievance types have become key indicators of a plan’s responsiveness and regulatory compliance.
Accurately identifying, documenting, and processing these grievances can be challenging for Member Service Representatives, especially when a member expresses dissatisfaction but declines to file a formal grievance. This article will outline these types of grievances and our most frequent questions around them.
It should be noted that while this article focuses on calls coming into member services, any representative of the plan could receive a grievance and should know how to document and respond to them.
On November 20, 2025, CMS released updated audit guidance for PY 2026. It is important to note that while it may sound like CMS is taking the gas off audits, the strategy has just changed to reflect a more comprehensive, global approach to audits and modernized their approach. The focus is on compliance governance and oversight and streamlining the administrative burden on both sides of the audit.
Here are the key changes:
- Extended Audit Season: Engagement letters will now be issued February through August, giving plans a longer audit engagement window.
- Removal of ICAR/ORCA: CMS is eliminating Immediate Corrective Action Required and Observation Requiring Corrective Action classifications, giving CMS greater discretion in determining corrective actions.
- Compliance Program Effectiveness (CPE) Discussions: CMS will integrate in-depth compliance discussions during program audits, focusing on real-world prevention, detection, and correction of noncompliance. In addition, CMS will be conducting quarterly meetings with Compliance Officers to discuss compliance posture.
- IDS Classification Remains: Invalid Data Submission findings will continue, emphasizing the need for accurate universes.
- Independent Validation Audits (IVA): CMS now has more discretion in determining when IVAs are required, reducing unnecessary burden.
- Continued UM Focus: Audits will still assess compliance with coverage and utilization management requirements.
BluePeak can help!
BluePeak offers customized mock audits across all CMS program areas, including FA, CDAG, ODAG, SNP, and CPE. Let us help you identify vulnerabilities and strengthen your compliance posture. Email info@bluepeak.com to schedule your mock audit today and turn stress into success.
