The Model of Care Overhaul You Can’t Afford to Delay: Why 2025 Demands a Mock Audit Mindset

If your Model of Care (MOC) was written before 2025, it’s already outdated.

With the release of the Centers for Medicare and Medicaid Services’ (CMS) draft MOC model documents, the introduction of the Dual Eligible Special Needs Plan (D-SNP) Questionnaire, and the implementation of the Contract Year 2026 Final Rule, the MOC has undergone a fundamental transformation. These are not incremental updates, they represent a strategic shift in CMS’s expectations. Your MOC must now reflect real-time operations, not just regulatory intent.

Why a Full MOC Overhaul Is No Longer Optional

The 2025 changes require more than a redline—they demand a rebuild. Here’s why:

• New National Committee for Quality Assurance (NCQA) scoring rubrics emphasize integration, person-centered care, and measurable outcomes.
• CMS’s D-SNP Questionnaire intends to replace narrative assumptions with auditable, plan-specific responses.
• Operational alignment is now mandatory. Vague statements like “we coordinate care” must be replaced with specifics: who, what, how, and when.

Plans that fail to modernize their MOC risk entering the cure process, receiving only a one-year approval, or facing audit findings due to misalignment between documentation and actual delivery.

At BluePeak, we routinely see even seasoned plans struggle with:

• Defining and supporting their Most Vulnerable Population (MVP)
• Aligning Health Risk Assessment (HRA) and Interdisciplinary Care Plan (ICP) processes with timeliness and stratification requirements
• Demonstrating Medicare-Medicaid integration in D-SNPs
• Developing realistic and detailed provider training plans

This is why we strongly recommend engaging a BluePeak Model of Care expert—not just to rewrite your document, but to ensure it reflects what your plan can actually deliver.

Mock Audits: The Next Critical Step

Once your MOC is rebuilt, the next question is: can you prove it’s operational?

CMS makes its expectations clear—plans are required to show that what’s documented in the MOC reflects actual operations and care delivery on the ground. That’s where BluePeak’s mock audits come in.

Mock audits are no longer just a compliance check—they’re a strategic rehearsal for what CMS and NCQA will expect in 2026 and beyond. They will help you:

• Validate operational alignment across departments and delegated entities
• Test documentation and workflows for HRA, ICP, Transitions of Care (TOC), and Interdisciplinary Care Team (ICT) processes
• Identify breakdowns in ICP implementation, such as incomplete or untimely care plans
• Detect TOC events that are missed, delayed, or not documented according to CMS expectations or are misaligned with the MOC
• Identify ICT processes that are ineffective, inconsistently applied, or misaligned with what’s described in the MOC

Mock audits also uncover hidden vulnerabilities—such as outdated provider directories, inconsistent care coordination practices, or gaps in outreach processes—that can lead to audit findings.