As you may have heard, the CMS Program Audit season has been slower this year due to contracting award issues affecting the pace. Despite this temporary slowdown, CMS’s commitment to conducting thorough audits remains strong, with an anticipated intensification of activities in 2026. BluePeak is actively assisting the majority of plans undergoing audits this season, providing valuable insights into CMS’s focus areas.
Why Now is the Perfect Time for Mock Audits: This slowdown presents a unique opportunity for organizations to conduct mock audits, ensuring readiness for the expected surge in 2026. By proactively preparing, sponsors can identify and address compliance issues, tailor audits to specific needs, and benefit from discounted rates available through August.
Understanding CMS Program Audits: CMS audits are comprehensive evaluations of plan sponsors’ adherence to critical program areas. These audits assess compliance across various domains, ensuring effective management and delivery of healthcare services.
Key Areas of Focus:
- Compliance Program Effectiveness (CPE): Establish robust controls to prevent, detect, and correct noncompliance.
- Part D Formulary & Benefit Administration (FA): Analyze denied claims and utilization management edits to ensure proper benefits.
- Coverage Determinations, Appeals, and Grievances (CDAG): Confirm adherence to processing timeframes and drug management protocols.
- Organization Determinations, Appeals, and Grievances (ODAG): Guarantee timely processing of service requests and claims.
- SNP Care Coordination (SNPCC): Evaluate Health Risk Assessments and individualized care plans for comprehensive enrollee support.
Why Act Now?
- Proactive Preparation: Utilize mock audits to identify and address compliance issues before the 2026 audit surge.
- Strategic Timing: Conduct audits in July and August to gather data, perform thorough reviews, and validate remediation efforts.
- Customized Solutions: Tailor audits to your specific needs and timeline, ensuring comprehensive readiness.
CMS Recommendation: Sponsors are encouraged to use CMS program audit protocols and tools to conduct mock audits. This practice aids in generating and validating universes, preparing data, and submitting universe information. Mock audits also help identify operational vulnerabilities and areas of noncompliance, ensuring readiness for actual program audits.
BluePeak Advisors can help!
Schedule your mock audit and start 2026 with confidence. Let’s discuss how we can assist you in navigating the upcoming audit season!
