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CMS Program Audit Changes Announced

The Centers for Medicare and Medicaid Services (CMS) has updated the Program Audit Process Overview document and we have posted the changes here. Plans should digest the changes as this will be the bible as to what to expect if you get a 2019 audit notice, from the receipt of the audit engagement letter and preparation of universe submissions to the actual audit itself and finally to validation and closeout.

As we have indicated, your chance of getting a program audit is increasing dramatically. CMS is now hitting almost 100% of enrolled lives every four years via plan audits. In 2019, audit notice letters will be sent March through July.

Major changes and noteworthy comments:

  • Of significance is that audit universes will still change in 2020. In July of this year, CMS announced it was not implementing the universe changes for 2019 but continuing the use of 2017/2018 ones in 2019. CMS still expects to include the updated audit protocols and record layouts in an upcoming 30-day notice for public comment.
  • The 2019 Call Letter announced updates to the validation audit process. CMS will require the hiring of an independent auditor for validation only when there are more than five non-CPE (Compliance Program Effectiveness) conditions that must be tested.
  • In 2019, CMS is suspending collection of CDAG, ODAG, and SARAG Supplemental Questions at the time of the engagement letter. CMS is encouraging plans to use the questions as a guide to determine non-compliance.
  • In addition, CMS is suspending its collection of Call Logs (record layouts Tables 16, 14, and 12 in the respective protocols). These are used to identify misclassification of coverage requests but will use other ways to look at this issue, such as looking at plan oversight of its call-routing process in the CPE audit segment.
  • It is also suspending collection of certain CPE data and documentation available via other means.
  • In addition, the following program area specific elements will be suspended from evaluation in program audits:
    • Formulary and Benefit Administration (FA) – Website Review
    • Special Needs Plans – Model of Care (SNP-MOC) – Enrollment Verification
  • While the MTM pilot audit was suspended in 2018, beginning in 2019 CMS will evaluate plans’ implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016 through the program audit process. This is being added given the major Opioid crisis in the nation. We have written twice on CARA and Drug Management Programs – here and here. In addition, major changes are slated in 2019 for the Opioid Monitoring program requirements. We are combing through those changes. It is taking longer than we expected but we should brief you on those next week.
  • CMS clarifies that beneficiary at-risk determinations under CARA will not be considered coverage determinations and at-risk determination data will not be collected in universes. However, beneficiary at-risk redeterminations will be reported as a part of the total redetermination count within universes.
  • In October of this year, CMS released a draft consolidation of Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive document. CMS says it has reviewed the comments and does not anticipate significant changes for the final release in February 2019. CMS will allow for sufficient time to implement any policy changes before being subject to a program audit on those changes.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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