Highlights from 2017 CMS Audit and Enforcement Conference

The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics:

  • 2017 Program Audits
  • Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan
  • Medication Therapy Management (MTM) Panel
  • 2016 Program Audit and Enforcement Report
  • Timeliness Monitoring
  • Civil Money Penalty (CMP) Methodology

The presentations and recordings of the morning and afternoon sessions are posted here. All sessions merit a review by Compliance and operational teams at sponsors and delegated entities alike. Apart from the communicated clarifications and content provided on the slides, CMS allowed for numerous question and answer periods, both after each session as well as at the end of the day. Here I capture highlights of those Q&As.

Can an Independent Auditor (IA) follow the same CMS process of providing samples 1 hour before webinar sessions? In regards to the IA process, most sponsors do follow CMS protocol when doing validation, but it does not really matter to us how soon samples are delivered. It’s ok if you get them a little sooner. Most IAs do use the same protocol and timing, but it is not prescriptive, which is why there is not a lot of guidance around how IAs should audit.

If we had a CAR for CDAG clinical appropriateness, would the validation audit focus on that CAR, or would the validation audit need to be a full-scale CDAG audit? When it comes to that, the sponsor simply needs to validate the condition. A full CDAG audit is not required; just that particular condition.

To what extent are Invalid Data Submission (IDS) conditions a problem in 2016? They were not terribly problematic. Last year there may have been eight across seven sponsors, but CMS would like to see those at zero.

Now that you have covered 94% of enrollment with Cycle 2 audits, when do you plan to start a third cycle? CMS is not sure and is still looking at that.

Can or will CMS share overall observations in Timeliness Monitoring regarding performance? CMS believes they will be able to this summer.

How does CMS come up with the common conditions in calculating CMPs? CMS takes this from the annual audit report.

When are CMP notices posted on the CMP website? CMS posts CMPs as a result of program audits before end of February. For CMPs not related to audits, the agency posts those immediately after they are imposed.

In regards to call log universe, do we include calls placed to other vendors as a part of normal business (such as calls to transportation vendor) which do not pertain to main customer service? No, CMS wants only calls going to the main customer service line.

Is it appropriate to report date request received as AOR receipt date, or should sponsor report initial receipt date as request received? For ODAG tables with these two fields, sponsor should populate as each column specifies. CMS does consider both fields when doing timeliness calculations.

Will CMS release a revised Compliance Chapter 9/21 to reflect change in Elements from 7 to 3, or is this just a change in methodology? CMS is actively revising manual guidance. Compliance program requirements are still the same, but audit approach has changed. Do not confuse the three audit elements (Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities) with the seven core elements outlined in chapter guidance.

Is there a timeline when CMS is expecting MTM audit activities to migrate from pilot to standard? At this point, it is not determined.

From a long-term perspective, considering validation is 150 days and MTM is a calendar year, how would this area be handled from a validation perspective? At this time, MTM not subject to validation. It is still to be determined if it will be subject to validation in the future.

How will appeals timeliness monitoring affect future audits? To the extent that the timeliness monitoring effort becomes annual, it would make absolutely no sense to review timeliness audit, but that change remains to be seen. However, there is a difference in that timeliness monitoring is a review of a snapshot of the year before. CMS may want to phase timeliness review out of program audits. CMS also answered the question from the perspective of the agency using results to target for audits. CMS noted they always like to compare data to audit scores and results to see if there is anything meaningful but confirmed there are no plans for that in the future.

“While CMS indicated they would not use results from the timeliness monitoring for referrals for audit, CMS did indicate they would study the results to see if there is a correlation to audit results,” says a colleague on the Operational Performance team.  “Knowing what is in your data and using it for process improvement should be on every plan’s radar.” Since CMS staff indicated that the timeliness monitoring could one day potentially replace the timeliness review on program audits, sponsors should get ahead of that curve by using their timeliness monitoring data for their own internal review.

As always, we love to hear your thoughts and perspectives on agency activities as well as your experiences in the government programs space. Keep an eye on this blog for more updates from my colleagues on this week’s conferences.


The Gorman Health Group 2017 Forum concluded recently in New Orleans with over 200 of our closest clients and partners. John Gorman provides key takeaways from the event here. Make sure to join us next year!

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