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.
Feeling the Madness! The 2020 CMS Program Audit Cycle Begins
This March, sports will not be the only excitement—health
plans are gearing up to receive audit notices as we enter the second year of
the four-year Program Audit Cycle. The ball is in your court… Your team’s
readiness depends on review of the current audit protocols and practice,
practice, practice. Are you performing “mock” auditing to identify risks?
The Centers for Medicare and Medicaid
Services (CMS) started the current audit cycle in 2019 with a number of audit changes
and process improvements to assist plans, including:
- Removal
of Audit Element Review: Suspension of the review of Call Logs and the
Website audit element from the Formulary and Benefit Administration protocol, as
well as removal of the Enrollment Verification audit element from the Special
Needs Plans Model of Care (SNP MOC) protocol. - Streamlining
Information: Release of the Program Process Overview document with the
Program Audit Validation and Close Out guidance, along with a Program Audit
Frequently Asked Questions (FAQs) on the CMS program audit website. - Compliance
Program Effectiveness (CPE) Protocol Changes: Includes
suspension of the CPE self-assessment questionnaire and several changes to the
CPE universes.
CMS is continually seeking “…to improve
audits by soliciting sponsor feedback,” and recently opened for comment on the
proposed changes for 2020. Some notable changes include reductions in audit
elements and protocols, such as:
- Removal of Part D Coverage Determinations, Appeals, and Grievances (CDAG) Table 9 (Standard Independent Review Entity [IRE] Auto-Forwarded Coverage Determinations and Redeterminations [SIRE]) and Table 10 (Expedited IRE Auto-Forwarded Coverage Determinations and Redeterminations [EIRE]), as well as removing Table 16 Call Logs.
- Reducing timeliness CDAG sample size from 75 to 65 and increasing Grievances from 10 samples to 20, likely to compensate for the removal of Table 16 Call Logs.
- Edits to the CDAG universe requirements, including updating the notification requirements to coincide with Parts C and D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance Section 10.5.3 and adding exclusion language throughout the remaining tables.
- Removal of ODAG Table 14 Call Logs and reducing timeliness samples from 65 to 60 cases and Clinical Decision-Making from 40 to 35, while also increasing Grievance samples from 10 to 20.
The industry anxiously awaits the
distribution of the updates, as the current audit protocols are set to expire
April 30, 2020.
GHG assists plans with implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.
CMS Seeks Comments to Proposed Audit Protocol Changes
In a Health
Plan Management System (HPMS) memo dated August 20, 2019, the Centers for
Medicare and Medicaid Services (CMS) announced they are seeking comments to
their proposed changes to the current program audit protocols, which expire in
2020. All protocol areas have updates
and clarifying language to the Audit Process and Data Request documents.
Noteworthy
changes include:
Compliance Program Effectiveness (CPE)
- Removal of the CPE Self-Assessment Questionnaire
Coverage Determinations, Appeals and Grievances (CDAG)
- Removal of the CDAG Supplemental Questionnaire
- Removal of Tables 9, 10 and 16
- Reduced the data integrity sample size to 65 (from 75)
- Increased the Grievance sample size from 10 to 20
- CMS is excluding cases that require an Appointment of Representative (AOR),
where no AOR has been received, in Tables 1-8, 14 and 15
Formulary Administration (FA)
- Removal of the ‘Website’ section of the Audit Process and Data Request
- Increased the Transition sample size from 15 to 30, clarifying claim selection
will include both protected and non-protected class drugs
Organization Determinations, Appeals and Grievances (ODAG)
- Removal of the ODAG Supplemental Questionnaire
- Removal of Table 14
- Removal of ‘Dismissals’ from the data integrity sampling to reduce the
sample size to 60 (from 65) - Removal of OD approved cases from the Clinical Decision Making section,
reducing the sample size to 35 (from 40) - Increased the Grievance sample size from 10 to 20
- CMS is excluding cases that require an AOR, where no AOR has been
received, in Tables 1-2, 4-6 and 11-12
Special Needs Plan Model of Care (SNP MOC)
- Removal of ‘Enrollment Verification’ audit element
Additionally,
CMS has removed the Medication Therapy Management (MTM) audit area from the
protocols. Impact Analysis templates for
all audit areas remain unchanged. The
updated protocols, including a crosswalk of changes, can be found here. Comments are due to CMS no later than October
15, 2019.
The
trend in reducing burden to Plans continues with these proposed changes. Gorman Health Group (GHG) suggests internal
discussions related to the proposed changes start now so Plans are best
prepared when the finalized protocols are distributed.
GHG conducts mock audits that align with the CMS Program Audit Protocols? Contact us today for more information.
Resources:
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
Learn how a single platform designed specifically for Medicare can streamline enrollment and offer a better way to deliver a return on your plan’s investment. Click here
GHG Advisors is part of the Convey family of companies, which includes Convey Health Solutions, Pareto Intelligence, and HealthSmart International. Together, we collectively support healthcare organizations with elite consulting services and industry leading technology solutions. Learn more
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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
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.
Resources:
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!
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
Resources
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
Strive For Progress, Not Perfection, Because It Doesn't Exist
This week was a productive one for CMS and Compliance professionals. The 2015 Part C and Part D Program Audit and Enforcement Report was published on September 6, and the 2016 Fall Conference took place on September 8.
Highlights of the report include the publication of the most common conditions. CMS provided the frequency of the conditions from 2011 to present as well as the percentage of sponsors affected in 2015. Conditions which have been present six out of six years include the following:
- FA: Sponsor failed to properly administer its CMS-approved formulary by applying unapproved quantity limits
- FA: Sponsor failed to properly administer the CMS transition policy
- FA: Sponsor improperly effectuated prior authorizations or exception requests
- CDAG: Denial letters did not include adequate rationales, contained incorrect/incomplete information specific to denials, or were written in a manner not easily understandable to enrollees
- CDAG: Sponsor did not demonstrate sufficient outreach to prescribers or beneficiaries to obtain additional information necessary to make appropriate clinical decisions
"The repetition of these usual six only goes to show the complexity and ambiguity involved with ensuring beneficiary harm does not occur. The key is to identify and correct the issues before CMS makes a visit as well as having a long-range plan in place for continual improvement," says Charro Knight-Lilly, Senior Vice President of Client Relations. The report answers many commonly asked questions regarding methodology for sponsor selection, process improvement strategies, and enforcement actions. By having audited sponsors with such a large number of enrollees during the first year of the audit cycle, CMS hopes to cover 96% to 98% of beneficiaries enrolled.
The Fall Conference included a range of topics such as application updates, network adequacy, and anti-discrimination rules (the implementation of which continues to confound the industry). In my experience, some of the most valuable feedback comes directly from plan sponsor staff, and that was no exception on Thursday. Jenny O'Brien described UnitedHealthcare's shift from reactive and responsive to proactive, strategic, and innovative. Her words resonated about the need for Compliance staff to be this way. In all honesty, readers shopping around for a motto for a Compliance Awareness campaign should use those three words and call and thank her.
Based on Gorman Health Group's observations of 2016 activities, CMS is continuing with their audit schedule full steam ahead, but the science has still not been perfected — and it will never be. As much as CMS is working to refine audit processes to improve consistency and accuracy, that's what responsible sponsors do every day. Continue to share your feedback with CMS regarding their processes, and, as always, you can reach out to us for insight and assistance.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
How to Efficiently Conduct an Audit
Audits from regulatory bodies swarm around an organization like bees. And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come.
A key aspect of an effective compliance program is to ensure there is an effective system for routine auditing and monitoring along with a system to identify compliance risks. You've established what you believe to be a solid audit plan for the year, but other things just seem to get in the way. First, you're tasked with researching the requirements for a new plan type. Then you have a fire to put out with a delegate. One of your staff gets a job offer she can't pass up, and before you know it, your audit schedule for the year is derailed. You'll get to them, right? Let's just hope you don't receive an audit letter in the meantime. With every passing Monday you hold your breath, all the while wondering how much time it will be before the inevitable occurs.
Sometimes an extra set of hands is all that's needed to get your audit activities back on track, but you do not have the budget for another full-time employee. Think of the following member-impactful audits that can be accomplished while you handle other responsibilities:
- Part C and Part D Grievances and Appeals
- Member Enrollment and Disenrollment
- Marketing
- Coordination of Benefits
All audit plans should include not only aspects included in CMS' protocol but also include audits of other self-identified areas of risk. Any operations that touch member service or payment might be considered higher risk on your assessment. Are they? And are you able to accomplish them all with the resources you have? Does your staff have the right skillset for the audits? From a CMS Q&A:
The safeguarding of beneficiary rights and protections is arguably the most important responsibility of a sponsor. Demonstrating you have the resources to detect, correct, and prevent occurrences of non-compliance is a struggle when a department lacks things like the time, resources, or skill to perform certain audits. Contact us for ideas on how we can partner with you to efficiently conduct some of your audits, providing you with some much needed assistance.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
This Is the Year to Get It Right
Five consecutive years of very similar audit protocol, continuous partnering with sponsors to identify improvements, and numerous best practice/common conditions memos. Where are you in audit readiness? Did you evaluate the items in the 2016 Readiness Checklist sent in November? I will get back to that! In the meantime, the Centers for Medicare & Medicaid Services (CMS) has started sending audit letters, so we are aware of sponsors and Pharmacy Benefit Managers (PBMs) alike who are prioritizing CMS' requests. Early bird catches the worm, am I right? Presumably these plans have larger enrollment, since they will only be required to provide rejected claims for the one month of January.
Some priorities have not changed: Formulary Administration, Compliance Program Effectiveness, Organization Determinations, Coverage Determinations, Grievances and Appeals, and Model of Care activities are all still part of the base protocol. CMS has committed to releasing pilot protocol to review Medication Therapy Management (MTM) as well as Part C Provider Network Adequacy. Why this additional focus?
- CMS' focus on the reduction of opioid use may be one aspect of piloting the MTM protocol.
- The additional focus on Medicare Advantage (MA) networks is critical. In the past, there was not a requirement to evaluate providers to determine if they were open to new patients or not. If they were contracted and credentialed, then they were used for network adequacy. That does little good for a new member who cannot access that provider.
If you haven't done so, it is time to circle the wagons. CMS is managing a continuous cycle of new audits, audit report finalization, corrective action plan (CAP) review, and validation requests for a variety of sponsors. You cannot change past data, but you can put in place changes that could make improvements for you going forward. Nothing is more important (arguably) than ensuring your Compliance Program is strong. If you have a robust (and documented!) system for auditing and monitoring, you have a greater chance of finding shortfalls before CMS does. Earlier, I mentioned the 2016 Readiness Checklist, which was released on November 20, 2015. This is the sentence that keeps me up at night:
Should you identify areas where your organization needs assistance or is not/will not be in compliance, your organization must report those problems to your Account Manager directly by email in a timely manner.
While this could be viewed as a requirement to notify CMS upon checklist review (which should have been done prior to 1/1), a conservative interpretation would state that at any time, should you identify areas where the organization won't be in compliance, the organization must report to the Account Manager. If you look at it that way, then anything on that checklist pertinent to the program audit areas and identified as non-compliant in your audit period best be indicated as disclosed and not self-identified. Otherwise, CMS might ask why they didn't know about it prior. If you have not received an audit notice yet, do yourself a favor and evaluate your recent disclosures. The list you send to CMS will encompass items from January 1, 2016, through the start of the audit notice.
Resources
CMS audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more >>
Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Evolution of Validation: Selecting an Independent Auditor
The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA.
Let's go back to 2012. CMS was conducting the validation of audited Sponsors' corrective action plans (CAPs) by retesting areas found to be problematic. While the terminology has changed, the charge was led at that time by the Regional Office. In 2013, validation became an activity conducted by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) at Central Office and Regional Office staff. Any items that resulted in a Corrective Action Required (CAR) or an Immediate Corrective Action Required (ICAR) were subject to validation.
As part of the 2013 validation timeline, the Sponsor had seven days from the issuance of the final audit report to submit a CAP for each condition. If we reference the 2014 Part C and Part D Program Audit and Enforcement Report, CMS outlined the average number of days which elapsed after an audit notice was issued.
If we take a look at the average days elapsed from the Exit Conference to the Final Report Issued date, the number of days elapsed has decreased, from 241 days in 2011 to 99 days in 2014. Based on the last year of reported data, plans still had a healthy three months from the verbal acknowledgement of CARs and ICARs (that is, the Exit Conference) to the issuance of the final report in order to implement corrections. In theory, by the time the final report was issued, some issues could have been corrected and, therefore, could have been ready for validation. However, time had to elapse for CMS to approve the CAPs, and after that point, CMS allowed Sponsors another 90 calendar days from that approval to implement and test the results of those CAPs. That's a lot of time when you look at it from the beneficiary perspective.
Fast forward to today — CMS is exercising their authority to require a Sponsor to hire an IA in order to validate if deficiencies found during a CMS program audit have been corrected. In a memo released on November 12, 2015, CMS confirms they will not provide recommendations on IA firms. Instead, they require the Sponsor to attest to both the independence of the IA as well as an absence of conflicts of interest. They point to the 2010 guidance for the selection of a Data Validation auditor for examples of relationships not meeting the standard for organization independence.
We are united with CMS' recommendation that Sponsors solicit proposals to select an IA early in the post-audit phase. Speaking from the auditor standpoint, it is much better for all parties involved to plan early, so exceed CMS' expectations and seek proposals as soon as possible. It's better to have that agreement in place ahead of time, rather than waiting until CMS sends you their instruction to hire an IA. This will give you the time to evaluate your options, so you can best determine their experience and subject matter expertise. When you are accountable to CMS to validate corrections, it is particularly important to partner with someone you can trust to apply a skilled eye to the validation activities. Otherwise, you may be subject to further scrutiny by CMS, which is the last thing any Sponsor needs when coming to the close of their audit process.
Resources
Determining conflict of interest is the responsibility of the Plan Sponsor and can be subject to interpretation. Not every auditor that a Plan Sponsor has used in the past is necessarily a conflict of interest. Contact us for further questions >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and February 14 and pay $1,095, the price increases to $1,295.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>