Case Study: Aspire Health Plan (Leading Healthcare Consulting Service Provider) achieves an exemplary 0.54 CMS audit score with Optum

Leading Healthcare Consulting Service Provider - Customer Case Study

Leading Healthcare Consulting Service Provider, an HMO/HMO‑POS Medicare Advantage plan sponsor serving roughly 4,000 members in Monterey County, engaged Optum to identify compliance vulnerabilities ahead of an expected CMS program audit after a major reorganization and a BPO transition. The plan retained Optum’s Government Health Plan Audit Services (mock audit and CMS audit support) to stress‑test systems, data universes, and compliance processes and to prepare staff for a full CMS review.

Optum performed targeted mock audits using automated data‑universe assessments, reviewed call‑center logs and compliance policies, provided hands‑on remediation guidance and staff training, and supported the plan throughout the actual CMS audit. With Optum’s assistance the plan compiled 33 data universes in seven days, navigated CMS interactive sessions, and achieved an exemplary CMS score of 0.54—demonstrating markedly improved audit readiness and top‑tier compliance performance.