CMS Program Audit Universes and Protocol Changes Tabled Until 2022

The Centers for Medicare and Medicaid Services (CMS) recently released the 2021 Program Audit Memo, which announced that it will start sending engagement letters in March of 2021, and will continue to do so through July of 2021. CMS also announced that it will continue to use the 2020 protocols for program audits in 2021. CMS initially intended to use the updated protocols in 2021, but is still waiting for approval from the Office of Management and Budget (OMB).

CMS has stated: “Delaying implementation of the updated protocols proposed under CMS-10717 will give stakeholders sufficient lead-time to apply and test the updated protocols prior to CMS using them to conduct audits.”

Health plans should use the time to ensure that they and their Pharmacy Benefit Manager (PBM) have reviewed the updated protocols anticipated for 2022 to ensure compliance with data extraction and population. Of note is one of the new universes, “Universe Table 7: Comprehensive Addiction and Recovery Act (CARA) At Risk Determination (AR) Record Layout”. Plans should verify whether they are aligned with their PBM to define the responsible party and confirm that the layout has been reviewed and is ready for use in 2022.

CMS’s 2019 Part C and Part D Program Audit and Enforcement Report did not include the common conditions cited during program audits, as it has done in years past. This exclusion is unfortunate in that it is typically a helpful learning tool for plans to modify oversight activities and incorporate noted best practices into their operations. That being said, with the goal of ensuring member access to entitled benefits and focusing on noncompliance related to access to care, GHG would expect CMS’s areas of focus to include COVID-19 flexibilities and proper administration of opioids edits in Formulary Administration.

In the 2020 Part C Organization Determinations, Appeals, and Grievances (ODAG) protocol, CMS eliminated the Call Log universe (Table 14). In the Compliance Program Effectiveness (CPE) protocol, CMS suspended the CPE self-assessment questionnaire and made several changes to the CPE universes.

As we head into the 2021 CMS Program Audit season, take the appropriate steps to ensure that your health plan has updated its universe data pulls accordingly.


Where Do We Go from Here?

With all the stressors on health plans in the current environment and the ever-changing landscape of the COVID-19 pandemic, the news from CMS to continue use of the 2020 audit protocols may come as a bit of a relief. However, plans must not be complacent about audit preparation and should remain diligent about their PBM oversight activities. Plans are still encouraged to perform mock audits to evaluate their operations and practice the experience.

Gorman Health Group (GHG) assists plans in implementing process improvements in relation to new CMS requirements. Our team of subject matter experts also conduct readiness assessments and mock program audits to validate adherence and identify potential areas of risk or concern. Contact us today to start the conversation.

 


HHS Proposed Bill Could Revolutionize Current Rebate Pricing Model

Removal of Drug Rebate Safe Harbor Protection

The U.S. Department of Health and Human Services (HHS) issued the proposed rule to remove the safe harbor protection rebates involving prescription pharmaceuticals on January 31, 2019.

The proposed rule is looking to disrupt the current incentive structure of the drug payments, particularly to Pharmacy Benefit Managers (PBMs). The Administration believes the proposed regulation  would “…create incentives to lower list prices and reduce out-of-pocket spending on prescription drugs” and described the proposal “… to be the most sweeping change to how Americans’ drugs are priced at the pharmacy counter, ever, by delivering discounts directly to patients at the pharmacy counter and bringing much-needed transparency to a broken system.” In theory, I do not disagree but the question we always ask is what the downstream or unintended consequences are. Let’s look at a few of the details.

The
existing discount safe harbor would be amended to exclude reductions in price
paid by drug manufacturers to plan sponsors under Medicare Part D or Medicaid
managed care plans, either directly or through PBMs. Currently, drug companies
will negotiate with PBMs (on behalf of plan sponsors) for rebates off the list
price to achieve a lower net price, in exchange for volume or market-share
criteria and often for an advantageous formulary placement.  But who benefits from these rebates – well
the PBMs for sure and plans pay less than the list price.  Rebates are usually paid to the PBM after the
transaction at the point-of-sale (POS) and are usually not passed on to the member-
at least directly.  Some will argue that the
premiums are kept down in part- from the rebate savings. 

Creation of New Safe
Harbor Rules

The
proposal would create two new safe harbors, the first one would protect
discounts offered to patients at the pharmacy counter, as long as three conditions
are met:

  1. The
    reduction is price must be set in advance with the plan sponsor under Medicare
    Part D, a Medicaid MCO, or a PBM. CMS proposes that “set in advance” would mean
    that the terms of the reduction in price would be fixed and disclosed in writing
    to the plan sponsor under Medicare Part D or the Medicaid MCO by the time of the
    initial purchase.
  2. The
    reduction is price may not involve a rebate, unless the full value of the
    reduction in price is provided to the dispending pharmacy through a chargeback.
    CMS is defining “chargeback” as a payment made directly or indirectly by a
    manufacturer to a dispending pharmacy so that the total payment t the pharmacy
    for the prescription is at least equal to the agreed upon price in writing.  CMS is seeking comments to this definition.
  3. The
    reduction is price must be completely reflected in the price the pharmacy
    changes to the beneficiary at the POS. This price reflection would enable the
    dispensing pharmacy to have the necessary information to appropriately charge a
    beneficiary who owes coinsurance, even if the manufacturer ultimately tenders
    the dispensing pharmacy a payment through a chargeback to reflect this
    negotiated price with the payor.

The
second safe harbor would protect certain fixed fee arrangements between
manufacturers and PBMs if the following conditions are met:

  1. The PBM and the pharmaceutical manufacturer must have a
    written agreement that: (i) covers all of the services the PBM provides to
    the manufacturer in connection with the PBM’s arrangements with health
    plans for the term of the agreement, and (ii) specifies each of the
    services to be provided by the PBM and the compensation for such services.
  2. Compensation paid to the PBM must: (i) be consistent
    with fair market value in an arm’s-length transaction; (ii) be a fixed
    payment, not based on a percentage of sales; and (iii) not be determined
    in a manner that takes into account the volume or value of any referrals
    or business otherwise generated between the parties, or between the
    manufacturer and the PBM’s health plans, for which payment may be made in
    whole or in part under Medicare, Medicaid, or other Federal health care
    programs.
  3. Fees cannot be determined in a manner that takes into
    account the volume or value of any referrals or other business generated.
  4. The PBM must disclose in writing to each health plan
    with which it contracts at least annually, and to the Secretary upon
    request, the services it rendered to each pharmaceutical manufacturer that
    are related to the PBM’s arrangements with that health plan and the
    associated costs for such services.

Impact on the Pharma/PBM
Industry

  1. The
    system would develop a new type of per-prescription, plan specific rebate or retail
    discounts applied at point-of-service (POS).
  2. PBMs
    and plans would prefer a product, portfolio of products, or therapeutic
    category with the lowest net price rather than the largest rebate.
  3. Formulary
    placement would be determined by net discounted price, the number of
    competitors, and other factors. When comparing two comparably priced drugs, the
    incentive to select the one with the high-list/high-rebate over the lower list
    price drug is removed.
  4. Increasing
    the list price by drug manufacturers for a drug to offer a larger rebate in
    order to obtain better formulary placement would be eliminated.
  5. Price
    increases to list price could be limited to current business and economic
    conditions.

Impact on Medicare
Advantage

  1. Impact
    on plan bids would see the removal of the drug rebate pool from a plan’s
    revenue stream, eliminating the use of those dollars to buy down premiums or
    cost-sharing.
  2. Plan
    benefit design would change in favor of high utilizers who would experience a
    great POS rebates translated as lower cost-share. The greatest impact would be
    on the high-dollar/high-rebate drugs such as specialty and brand name drugs.
  3. Direct
    and Indirect Remuneration (DIR) reporting would be impacted. Although the
    proposed change has not yet been sufficiently developed to understand the real
    world impact, based on the current reconciliation model, reinsurance subsidy
    would be impacted.
  4. The
    Star Ratings impact CAHPS scores is a wild card. If most members experience
    increased premiums and cost-sharing, masses of dissatisfied members unhappy
    with their plans are a likely sequelae.

Summary

How this all shakes down, and
when is to be determined. The goal is to create incentives to lower list prices
and reduce out-of-pocket spending on prescription drugs. But, getting from
where we are now to achieve this goal is not a simple path. Let’s face it, all
entities impacted are in the business of making money and when squeezed in one
area may look to recoup in another. 

Even the Administration
appears to be uncertain about the downstream effects of the AKS safe harbor removal
and has stated as such in the proposed rule. 
Actuarial analysis have predicted savings or $190 billion to losses of
$100 billion in rebate dollars. They acknowledge the complexity and uncertainty
of stakeholder behavior.  CMS is open to
comments regarding the proposed rule and the aggressive timeline proposed.


Changes for How Biosimilars are Reimbursed

Biosimilars have finally been accepted by the popular crowd. Coverage year 2019 (CY2019) is going to see some changes for how biosimilars are being reimbursed. In 2015, the first biosimilar product, Zarxio (filgrastim), was approved in the U.S. An approved biosimilar is a medication that has been shown to be highly similar to a Food and Drug Administration (FDA)-approved biologic, the reference product. Only minor differences in clinically inactive components between the biosimilar and reference product are allowed, and there must be no meaningful clinical differences. However, a biosimilar is not considered a generic drug, which is approved through a different pathway. Due to the inherent complexities of biologics, it is not possible to make an identical copy of a biologic. Traditional, small-molecule drugs are made through a predictable set of chemical reactions, but biologics are made using manufacturing processes (e.g., cell production, purification processes) and living organisms (e.g., cell lines) that are unique to each manufacturer. Although not a generic from a molecular or manufacturing perspective, biosimilars do function as a generic in intent. Meaning, biosimilars help increase access to biologic medications and potentially lower healthcare costs through competition. There have been several company announcements touting the cost savings potential of biosimilars. A recent example is Mylan’s approval of it’s biosimilar Fulphila, which has promised that it will come to market with “double-digits reduction” in price compared to the reference product Neulasta.

The topic of drug pricing transparency and reform has been addressed by the current administration. At the recent Pharmacy Quality Alliance Annual Meeting, the Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma spoke about “The American Patients First Blueprint” and the four-pillared strategy. The four pillars are as follows:

 

1. Reducing Americans’ out-of-pocket spending
2. Increasing competition in the drug market
3. Improving negotiation to get a better deal for patients and taxpayers
4. Creating incentives for manufacturers to lower list prices

 

As part of this initiative, the access to biosimilar agents was addressed. Biologic products are among the most expensive medications on the market today and include treatments for cancer, diabetes, rheumatoid arthritis, and multiple sclerosis. The Biologics Price Competition and Innovation Act (BPCI Act) created an abbreviated licensure pathway for biological products that are demonstrated to be biosimilar to or interchangeable with an FDA-approved biological product. Within the Medicare Part D program, biosimilar uptake has been dependent on a number of factors, with formulary inclusion/placement being significant. In general, plans encourage use of lower-priced products, but current coverage gap discounts have provided financial advantages to the reference biologic products. This approach incentivized inclusion of the biologic reference products and resulted in beneficiaries potentially having higher cost sharing.

 

Essentially, when the beneficiary is in the “donut hole,” his/her resulting scenario is higher out-of-pocket costs for lower-cost medicines. Passage of  the Bipartisan Budget Act of 2018 (BBA)  has provided forward momentum for biosimilar uptake. The BBA, enacted on February 9, 2018, amended the definition of “applicable drug” for purposes of the coverage gap discount program to include biological products (finally). Effective CY2019, biosimilar and interchangeable products will be “applicable drugs” for purposes of the coverage gap discount program. This policy change ensures patients in the “donut hole” won’t get stuck with a bigger bill for the biosimilar than the reference product. It is important to note that while biosimilars are considered applicable drugs for manufacturer GAP discount purposes, they are still considered to be generic entities for Low Income Cost-Sharing Subsidy (LICS) purposes.

 

Part D Sponsors should make sure measures are in place to ensure biosimilar claims are adjudicating and being reimbursed as expected for the 2019 changes. GHG’s Pharmacy Solutions experts can assist you with operationalizing the new regulations. Contact us today!

 

 

Resources:

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Audit Engagement Letters Will Start in March

If you did not have the pleasure of being part of a Centers for Medicare & Medicaid Services (CMS) Program Audit in 2017, don’t be caught off guard if you receive your invitation this year.

Audit engagement letters will start going out this month.

CMS has made few changes to the 2018 CMS program audit protocol from 2017. However, one change was for the Call Log submission for Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG). With the exception of Medicare-Medicaid Plans (MMPs), the number of call days required to be submitted varies based on the plans sponsors’ enrollment.

While helping plans survive the CMS program audits last year, Gorman Health Group observed one standout area of struggle: call logs. The addition of call logs to the audit protocol relates back to ensuring plan sponsors are appropriately classifying and handling grievances, coverage determinations (Medicare Part C and Medicare Part D), and member notifications. It really boils down to customer service and proving your representatives are handling the cases appropriately. The importance of customer service cannot be stressed enough. At the heart of every business is good customer service. Within the Medicare space, any opportunity to make the member experience a positive one is important from both a quality of care and Star Ratings perspective. Call logs are a means to assess current service levels and to identify training and improvement opportunities. There are now vendors who utilize artificial intelligence to detect the emotions of the caller and how to handle the call appropriately—if the caller is frustrated, they may need to be handled as a grievance.

If you have not established an oversight program or performed a universe pull for call logs, don’t wait any longer! Identifying any issues with data integrity and the service/information provided by your customer service representatives is crucial. Pay particular attention to how the calls are being documented and the reliance on vendor or inter-departmental communications. You want to ensure call transcripts are entered into your system and notes would easily walk an auditor through the case from the time the call was answered through to resolution and that it has been sufficiently documented. If there is a gap in your current process, it is time to put a plan in place.
Gorman Health Group can assist your plan with mock audit services ranging from a complete program audit to a specific, targeted audit of your call logs. The time to act is now to avoid getting caught with your pants down.

 

 

Resources:

Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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The Achilles Heels of Part D in Program Audits: FA and CDAG Administration

This may seem like the movie “Groundhog Day,” but Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) continue to hobble plan sponsors’ Centers for Medicare & Medicaid Services (CMS) program audit results. Failure to properly administer their CMS-approved formulary continues to plague plan sponsors. As a result, enrollees experience inappropriate denials of coverage at the point of sale and were delayed access to their medications, never received their medications, or incurred increased out-of-pocket costs in order to receive their medications. Plan sponsors continue to be tripped up in the following areas of FA:

Administration of CMS-Approved Formulary

  • Rejecting prescriptions for formulary medications that were written by out-of-network providers
  • Improper coding of the approved drug list
  • Failure to allow claims for extended day supplies on initial prescriptions
  • Failure to appropriately test and/or implement coding of quantity limits (QLs) in the adjudication system, resulting in inappropriate rejections

Administration of CMS Transition Policy

  • Improper look-back period of member history
  • Did not register beneficiaries’ historical claims in a timely manner, which led to sponsors not properly identifying beneficiaries’ historical drug regimen and eligible transition fills
  • Denied beneficiary access to transition fills as a result of errors in enrollment data; for example, beneficiaries who were new enrollees were coded as continuing enrollees
  • Failed to allow claims for formulary drugs dispensed in the smallest commercially available package size when the day supply, based on the prescribed dose, exceeded the plan’s day supply benefit
  • Processed transition fills for only some of the drugs that were subject to a cross-contract year formulary change
  • Processed concurrent drug utilization review edits as safety edits during transition, thereby inappropriately restricting drug access during the transition period

Effectuation of Prior Authorizations

  • Not dating the effectuation for approvals to the earliest request of drug purchase date resulting in enrollees’ delayed or denied access to prescription drugs, having to receive formulary alternatives, or having to pay out-of-pocket in order to receive their drugs

Application of Quantity Limits

  • Utilized maximum daily dose limits that were more restrictive than the CMS-approved QLs and/or Food and Drug Administration maximum recommended daily doses
  • Applying incorrect adjudication logic for the type of QL submitted on the approved formulary (Type 1 QL Qty/Time submitted but applying Type 2 daily dose logic prevents partial refills)
  • Applied QLs to non-formulary medications

Application of Step Therapy

  • Using improper look-back period to establish prior drug history
  • Applied prior authorization edits on claims for beneficiaries with a utilization history of protected class drugs

CDAG findings remain a costly area for plans. To date in 2017, 10 plans have been hit with a civil monetary penalty (CMP) – 80% of them were cited for a violation related to Medicare Part D CDAG requirements.1 Plans should be reviewing the common conditions and evaluating their own practices to identify risk areas. A compliance and operational assessment should be completed prior to CMS audit activities to ensure adequate staffing and oversight is in place to avoid potentially costly audit findings. The most common cited conditions seen year over year remain the following:

  • Denial letter rationales
  • Untimely Independent Review Entity (IRE) auto-forwards
  • Insufficient prescriber outreach
  • Untimely decisions and/or notifications
  • Not effectuating exceptions through the end of the plan yea
  • Misclassification of coverage determination or redetermination requests as grievances and/or customer service inquiries

Other areas which were cited in the CMPs and represent additional case selection potential in the 2017 draft audit protocols are the following:

Misclassification of reconsiderations as organization determinations or re-openings

  • Re-openings are considered a remedial action that should be used sparingly. Inappropriate use of this procedure would delay case forwarding to the IRE, thereby delaying or denying enrollees’ right to the appeal process.

Improperly dismissed coverage request

  • Dismissing a coverage determination instead of making a decision (approval or denial) should be done in very limited circumstances, usually limited to cases where a review is not required (e.g., party requesting coverage is not a proper party). If dismissed inappropriately, enrollees are denied access to the appeals process, which may result in delayed or denied access to medication.

 

1(https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/PartCandPartDEnforcementActions-.html_

 

Resources:

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


Perhaps a Visit to the Physical Therapist Is in Order – Make Sure Your CDAG Process Is Not a Weak Spot

Coverage Determinations, Appeals, and Grievances (CDAG) remain a compliance Achilles heel for many Part D sponsors. The Centers for Medicare & Medicaid Services (CMS) has noticed! Challenges with interpreting CMS regulations and guidance and operational restrictions have the potential to create a very costly gap. CMS is increasing scrutiny of this area in 2017.

CMS identified this weak spot and has provided additional communications via the Common Conditions, Improvement Strategies, and Best Practice memos, Job Aids, and proposed clarifications in the 2018 Draft Call Letter. The 2017 Draft Audit Protocol proposes expanded case selection in the Clinical Decision-Making (CDM) 2017 Program Audits and increasing enforcement actions related to Part D Auto-Forwards.

GHG’s experience in assisting plans with Part D operational assessments and participation in CMS Program Audits has identified the following areas for greatest risk of non-compliance:

Timeliness – Despite overall improvements in recognizing the importance of adhering to the processing and notification regulatory time frames, many plans still struggle. On December 16, 2016, CMS released a memo describing their intent to increase the compliance to enforcement escalation process and intent to issue Civil Monetary Penalties (CMP) on a quarterly basis to sponsors that fail to meet an established threshold. The expected CMP outlier threshold is 15 or more auto-forwards per 10,000 beneficiaries per quarter. For smaller plans whose enrollment is less than 800, fewer than 10 IRE cases/appeals per quarter, and fewer than 10 auto-forward cases per quarter will be excluded from the analysis.

Classification and Processing of Re-Openings – GHG has observed sponsors that liberally utilize the reopening of coverage determinations and decisions. Sponsors may reopen a case, as a remedial action, under certain conditions; however, CMS expects plan sponsors to limit their use of the reopening procedure, so don’t get carried away! The reopening procedure must be used to process clerical errors but not the failure to execute the determination process itself to ensure enrollees have been afforded appropriate appeal rights. This scenario is on CMS’ radar for the 2017 Program Audits. Based on the draft protocol, an additional five cases may be selected for review to assess appropriate classification and processing of dismissals, withdrawals, and/or reopenings.

Tiering Exceptions – If your benefit is set up with a mix of brand and generic drugs on a formulary tier, you may need to loosen the purse strings. If a formulary tier contains both brand and generic drugs as determined by New Drug Application (NDA) and Abbreviated New Drug Application (ANDA) status, some sponsors have been incorrectly denying tiering exception requests. Many Immediate Corrective Actions Required (ICARs) were issued for this reason during the 2016 Program Audits. In the 2018 Advance Notice and Draft Call Letter, CMS provides clarification about their expectations for tiering exceptions. If a plan sponsor has a mixed tier, the lowest tier would be the tier containing alternatives to the requested drug. Make sure to review your formulary and understand the CMS definitions of “brand” and “generic” to appropriately assess your tiering exceptions procedures!

For a hands-on workshop on CDAG, plan to attend the GHG Forum April 26-27, 2017, in New Orleans. Our Conference Brochure and Preliminary Agenda Is Now Available!  Download it to see the additional topics we have in store for you at this year’s event.

Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

 

Resources

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


Lessons on the Audit Front

The regulatory scrutiny continues. The Centers for Medicare & Medicaid Services (CMS) 2016 Compliance and Program Audits are in full swing, and it is readily apparent plan sponsors must be "audit ready." CMS' intent to hold plan sponsors accountable to comply with Medicare standards and ensuring beneficiary protection is evident. Plan sponsors must be ready to take the test.

It all starts with the data…make sure you get it right! The invalid data submission (IDS) was a condition added to the 2016 scoring methodology. CMS has emphasized the need for plan sponsors to validate all data submission before they are uploaded. The "Three Strike Rule" applies. If the sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in the audit report. After the third failed attempt, or if an accurate universe cannot be produced in fewer than three attempts due to missing or unavailable data, an IDS may be cited.

Speaking of audit scoring methodology, confusion appears to remain regarding the audit scoring method. Samples are no longer given a pass/fail score with a specified passing score of 95%. Issues are now identified as conditions. One condition may apply to multiple samples. CMS will evaluate the condition by the potential impact on the beneficiary as either an observation, Corrective Action Required (CAR), or Immediate Corrective Action Required (ICAR). The audit score is generated based on the number of non-compliant conditions discovered; the maximum audit score is unlimited.

Thus far in 2016, the most common conditions cited by CMS are ones we have seen before. Plan sponsors' failure to properly administer its CMS-approved formulary, usually due to a coding error by the Pharmacy Benefit Manager (PBM), remains a risk area. It is critical for plan sponsors to have an adequate oversight monitoring program to identify and remediate issues expeditiously.

Coverage Determinations, Appeals, and Grievances (CDAG) continue to be a low performer in 2016 CMS Program Audits. It is important for plan sponsors to connect the dots with end-to-end case preparation, and remember — nothing is off-limits. CMS can open any can of worms that is identified as a risk. Coverage determination notification letters remain a targeted area. Plan sponsors must have the necessary quality checks and/or oversight to ensure notification letters are specific to the enrollee's case, accurate, and provide the information needed to approve coverage in the case of a denial. This is a recurrent finding from prior years which CMS has cited in Best Practice Memos, so there is a low tolerance for inadequate denial letters.

New to the 2016 audit cycle is the Medication Therapy Management (MTM) Program Pilot Audit, which is conducted virtually in the second week. Despite the fact results of this pilot are not included in the plan sponsor's final report, CMS is not taking this audit casually. "The goal of this audit is to evaluate the implementation of the plan sponsor's adherence to its CMS-approved MTM Program," said a subject matter expert on our Pharmacy Solutions team. Be sure you are ready to tell the case story. "CMS has been particularly interested in looking at the continuity of care across plan years for members who received a Comprehensive Medication Review (CMR) in the previous year. This is one area which appears to be especially disconnected if plans may have had multiple MTM vendors or changed PBMs," continued Miller. "Coordination of information flow, especially for enrollee's year-over-year tracking, is essential." Plan sponsors that incorporate strategies for a ready state for CMS audit will be more successful. The conduction of an MTM Program mock audit is an effective way to identify shortfalls and issues in your data collection, accuracy, and overall readiness — before you are presented with a CMS audit engagement letter.

Another challenge noted in the 2016 audit front is, despite CMS process enhancements, auditor inconsistency. This presents a challenge in what a plan sponsor can expect. In order to be prepared for a program audit, plan sponsors should prepare by exceeding CMS' expectations, not just meeting them.

Resources

Our highly structured mock CMS audit services are designed to replicate the latest CMS audit processes.  Our team of industry veterans is ready to help your organization practice and learn the new CMS audit protocols; new universes and many more data fields, interviews via a webinar, and of course the CMS protocol documents. Visit our website to learn more about our CMS Mock Audit services >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>