The annual Centers for Medicare and Medicaid Services (CMS) Audit Season has been in full swing since the beginning of the year with a focus on Utilization Management. CMS is making great efforts to achieve their goal of auditing 88% of the Medicare Advantage membership this year. Below are four (4) common conditions and their specific questions to ask yourself to ensure you are compliant:
- Sponsor did not establish a utilization management (UM) committee in accordance with composition requirements.
- Is the UM Committee chaired by a plan medical director?
- How does the plan define “practicing physician”?
- How does the plan evidence that a physician is practicing?
- How does the plan define free of conflict?
- How does the plan document conflicts of interest disclosures?
- What is the review process for clearing conflicts?
- How does the plan handle recusals?
- Sponsor used utilization management (UM) policies and procedures that were not reviewed and approved by the UM committee.
- How have Part B drug policies been reviewed and approved?
- Has the UM Committee reviewed and approved Part B drug policies?
- Does the plan rely upon its P&T committee to review and approve Part B policies?
- Is that compliant with the new regulations?
- Have all of the plan’s clinical criteria been reviewed and approved by the UM Committee?
- Have all of the plan’s administrative policies been reviewed and approved by the UM Committee?
- How have Part B drug policies been reviewed and approved?
- Sponsor’s Utilization Management (UM) committee did not review and approve UM policies and procedures for supplemental benefits.
- Have all plan’s supplemental benefits and First-Tier, Downstream, and Related Entities (FDRs) been inventoried?
- Do existing FDRs use the plan’s clinical criteria and administrative policies or their own?
- If the FDR uses its own clinical criteria and administrative policies, what is the process for the plan to review and approve such policies, timely?
- Sponsor did not make internal coverage criteria publicly accessible.
- How many steps does the individual need to take before being able to access the plan’s policies and procedures?
- Were these all posted timely (by 1/1/2024), including those of third-party entities?
- Are all FDR clinical criteria posted?
- Is the posted information easy to find?
- How many steps does the individual need to take before being able to access the plan’s policies and procedures?
BluePeak can help.
If there are gaps or you have questions regarding the above conditions, please feel free to reach out to discuss CMS expectations and industry happenings with a BluePeak Subject Matter Expert by emailing info@bluepeak.com.
