@Regulatory: October 2011Leading practices to support compliant practices for short-stay admissions |
@Regulatory covers the latest developments across the health care provider, health plan and life sciences industries.
The Centers for Medicare and Medicaid Services (CMS) has changed its approach to auditing Medicare plans— specifically Medicare Advantage (MA) and Prescription Drug Plans (PDP) - from auditing one-third of plans each year to a risk-based approach to selecting plans for audit. CMS reviews the data and information they receive from MA and PDP organizations, Medicare beneficiaries, and other government entities to identify outliers or plans that raise red flags in how they may be functioning. In its analysis of plan data, CMS has identified certain MA and PDP functions as high risk and has targeted those functions for audit. The areas that CMS has focused on auditing include formulary and benefit administration; part D coverage determinations, appeals (CDAs), and grievances; broker and external agent oversight; and the plan’s compliance program. CMS is taking an outcomes-based approach to conducting the audits and is reviewing plans for their operating results. However, the current audits are not the same as the audits performed using the prior audit guides. Plans must produce information much more quickly than in the past, and rather than CMS reviewing paper-based case files, it reviews live systems when on site for the performance audit.
To prepare for a CMS audit, plans should show that their operations are functioning according to their CMS contract and demonstrate that compliance issues identified in the course of business are addressed and corrective actions taken. The article below presents CMS’ performance audit approach and tactics over the past 12 to 18 months. Although it is expected that CMS will continue this audit approach, it may change its audit tactics going forward.
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@Regulatory: October 2011
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