2023 CMS Program Audit Trends and Key Details: What We Know So Far

On November 30, 2022, the Centers for Medicare and Medicaid Services (CMS) Medicare Parts C and D Oversight and Enforcement Group (MOEG) announced the 2023 program audit updates.  CMS is continuing to use the Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) and the 2022 MMP Audit Protocols and Data Requests to conduct 2023 program audits.  For the 2023 program audit season, CMS will send program audit engagements letters from February 2023 through July 2023.  Now that we have reached the mid-point of the program audit season, let’s recap trends and key details that BluePeak has observed while supporting clients through their program audits.

Organization Determinations, Appeals, and Grievances (ODAG)

CMS continues to focus on written notifications, date claim paid, as well as good cause.  Other areas identified this year include the following:

• Processing of Coverage Requests
  • Pre-service denials (initial and reconsiderations)
  • Post-acute care
  • High tech imaging
  • Part B drugs
  • Denials for no out-of-network benefit – Was medical necessity review for going out of network conducted?
  • Payment organization determinations
    • Denials for lack of medical necessity to review clinical review process
    • Claims associated with plan directed care
  • Classification of Requests
    • Dismissals chosen based on dismissal reason to sample cases for each dismissal reason included in universe
    • Quality of care grievances – Was a meaningful quality review conducted and the correct written notification provided?

Special Needs Plans (SNP)

• Additional case files requested after audit session
• Detailed review of provider training
• Review of how Sponsors who offer a D-SNP implemented the requirements from (CMS-4185-F) to understand how D-SNP enrollees are provided the assistance outlined in the regulations (see CMS memo “2023 Program Audit Updates” issued November 30, 2022)

Coverage Determinations, Appeals, and Grievances (CDAG)

In addition to CMS’s usual focus on the appropriate classification of cases including exceptions, Medicare Part B vs Part D drugs, and enrollee/enrollee’s representative and provider notification, other areas of interest include the following:

• Processing of Coverage Requests
  • Appointment of representative (AOR) cases
  • Payment coverage determination cases that also required a clinical review
  • Coverage determination (CD) and redetermination (RD) reviewer and confirmation of appropriate type of reviewer at the CD And RD level as well as different reviewer at each level
  • Approvals
    • Level of effectuation (e.g., GPI-10 vs GPI-12)
    • Claim history demonstrating paid claim with approved prior authorization as well as no inappropriate rejections since approval date
    • Test claim in instances where a paid claim was not present
  • Requests for immunosuppressants – confirmation of transplant flag on member record and demonstration of payment under Part B when denied under Part D
  • Timing of outreach to providers for missing information
• Classification of Requests
  • Appointment of representative (AOR) cases

Formulary Administration (FA)

Prior authorization, step therapy, quantity limits and non-formulary drugs continue to be areas of focus.  However, CMS also targeted the following:

• Drug Management Program – reviewed plan’s policy and ensured DMP edits were not applied in the long-term care (LTC) setting
• Opioid safety edits

Compliance Program Effectiveness (CPE)

• Tracers should be chronological and only include relevant information
• Questions focused on the following:
  • How issues of non-compliance were communicated
  • Compliance oversight of corrective actions
  • First tier, downstream, or related entity (FDR) oversight