Annual Compliance Program Audit: Your Organization's Achilles Heel?
When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is audited annually. Fulfilling the requirement to annually audit the Compliance Program can present an issue for some Organizations due to the fact that Compliance Department self-auditing does not fulfill the requirement, and there may be no other department within the Organization with the expertise to conduct the review.
Here are a few ideas that we've seen Organizations use in order to fulfill the CMS requirement:
- Hire an external auditing firm.
- Cross-train another department within the Organization to conduct the annual audit.
- Compliance departments of two different Organizations audit each other. Of course, this option may be a bit tricky depending on the competitive landscape. However, it can be a good option if there is no budget to hire an external firm and if no conflict exists (e.g. competing service areas).
An effective Compliance Program is critical to your compliance and operational success. In addition, a strong Compliance Program can safeguard against many compliance issues recently cited by CMS as the cause for civil monetary penalties (CMPs) and enrollment sanctions. Please contact us for more information about the GHG Compliance Program Effectiveness Audit.
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CMS Validation Process: The Silver Lining
We've seen quite a few changes over the past few years in the way that the Centers for Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it will require the Organization "to hire an independent auditor to conduct validation in all operation areas cited in this notice and to provide a validation report to CMS." In addition, CMS presenters at the CMS Fall Conference, which took place on September 11, 2014, stated that "The onus of correction overall is on the sponsor. Therefore, CMS this year will not request universes to conduct sample testing unless the sponsor is unable to demonstrate through its presentation and from the responses to CMS questions, that it has not corrected the findings."
CMS is sending a clear message here. They expect the Organization, and not CMS, to do the work in the validation process. So, is there a silver lining? Why of course there is.
While it's clear that CMS is tightening the reins, they are also providing an opportunity - the opportunity to get it right the first time, and not go through the full CMS validation audit process. If you don't know the best way to proceed, in order to avoid a validation re-audit, we have the roadmap. Contact us today to get started.
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Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings
Is it Groundhog Day or does this memo say the same thing as last year? Nope you're not imagining things - In CMS' Memo titled "Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews" that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common areas of noncompliance identified as a result of CMS Program Audits. You may be saying to yourself "some of this looks familiar" well — you're right.
In fact, it appears that CMS is getting weary of repeating themselves year over year and they've included some language with teeth in this most recent memo. CMS makes two key statements in the 2014 memo — the first is that due to the number of repeat findings year over year, it has been determined that Organizations are not using this memo as CMS intended. The second, and more pointed statement is that Conditions noted in one or more memo will be considered "aggravating circumstance" during an audit and this may adversely affect the overall audit score.
So — what does this mean to your Organization? It means that if you haven't yet done so, now is the time to review each best practice memo provided by CMS and ensure that the recommended process is in place. If not, it's time to create and implement a corrective action plan for each best practice mentioned by CMS that would apply to your Organization. Remember, CMS understands that Organizations aren't perfect, but demonstrating that you're able to identify issues and put a plan in place to remediate those issues is always required.
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The Clock is Ticking...
If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial Risk Adjustment reporting and not quite sure of what programs you should be doing this time of year.
GHG has experienced Risk Adjustment analysts and consultants that can help you meet and exceed your yearend goals. Below is our checklist of processes you should be doing now to help ensure complete and accurate Risk Adjustment data reporting for yearend:
- Implement analytics that appropriately consider the new Medicare blended HCC model.
- Suspect targeting for Medicare and Commercial chart reviews — Employ a targeted approach to cast a wide net, but optimize program results.
- Suspect targeting for 2014 Medicare and Commercial member outreach — Member calls, in-home assessments, provider interventions — one approach alone won't get you there.
- Chart review execution — Know what your vendors are coding (do they include Rx HCCs?). Could computer aided coding reduce costs and improve ROI? What is the quality of the vendor reviews...would they hold up in an audit? Are they also looking to delete codes?
- Commercial Risk Adjustment — Select an independent vendor to perform your required audits.
- Audit Readiness — Execute the appropriate data quality audits now to minimize audit risk next year.
- ICD — 10 — Revisit or develop an implementation plan…ready or not here it comes!
Plans need to be proactive in their data capture to submit data before the January 31, 2015 deadline for Medicare and April 30, 2015 deadline for Commercial. Data accuracy also needs to be a priority with both programs to minimize audit risk and government take-backs.
Our team of experts can show you the way. Please contact us today.
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