Medicare Program Audits — Four Things Operations Should Be Doing Today
Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes. Instead of showing your department, processes, and system capabilities, CMS is getting the impression you don’t even know your data well enough to pull a correct universe. What can Operations departments do to get ready? Here are four things you can begin doing today to be ready:
- Set up automated universe pulls, both with internal systems and delegates. Automating these processes will allow you to pull them quickly and use them on a regular and ad hoc basis. Additionally, automating the process will help you identify which fields are not being captured properly or at all in your system. This can be the biggest difficulty in pulling universes and not something you want to find out when you receive your CMS audit notice. Start this process today.
- Learn to use the data in the CMS audit universes. CMS uses these formats for a reason. CMS has fine-tuned this process to allow them to most readily identify outliers and potential issues. This will help you as you monitor your own operational departments and identify hidden trends. It will also help you regularly monitor your delegates.
- Set up time to complete mock audits of the potential outliers. Pick 10 sample outliers on a monthly basis to review to determine if there are issues with your processes or universe pulls. It makes sense to do this within each operational area internally. You should know what is happening within your department before anyone else identifies it; this includes members, Compliance, or CMS. You will be surprised what you will learn through this review.
- See it to the end. Think like CMS when you complete your reviews. Put aside your thoughts on system limitations and department politics and how many times you have tried to address an issue. How does what you find impact members? How does this follow guidelines? If you identify issues, complete the process by running a beneficiary impact and root cause analysis. This will let you know scope and give you the information you need to address the issue. This may be supplying the information to allow a prioritization of a fix you haven’t been able to get prioritized before.
When we in Operations see CMS audits as something that is managed by Compliance, we do ourselves a disservice and lose out on one of the most valuable tools we should all have in place. Implementing these processes will change the dynamics of your department, promote ownership, and make a live CMS audit easier.
The Gorman Health Group Operational Performance practice consultants have been in your shoes. We have faced the multiple priorities and pressure to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department, we can help.
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