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CMS Continues to Scrutinize Part D Claims and Coverage Determinations Process through Program Audits and Notices of Non Compliance

By September 7, 2022September 30th, 2022Fall 2022, Part D

CMS Program Audit season is over and as anticipated, the volume of Program Audits in 2022 increased substantially over prior years. From a Part D perspective, audits have touched almost every large PBM and large health plan in the industry.

Formulary Administration audits continue to find issues with formulary rejections with scrutiny on Part B versus Part D determinations and accurate prior authorization processing, with a focus on prior authorization (PA) and step therapy (ST) Type 2 (New Starts) edits.  In some audits, CMS targeted samples that rejected for excluded prescriber and requested details on a Sponsor’s process for managing and identifying excluded providers.  Audits still show evidence of issues with enrollment processing and setup causing conditions that impact the enrollee’s transition benefit.  Administrative rejections also remain highly visible with CMS reviewing enrollment dates to validate enrollment processing is timely and doesn’t negatively impact the enrollee experience.

Protected class drug products with a prior authorization or step therapy restriction for new starts are being closely reviewed to ensure enrollees have continued access to these medications with either a prior fill or when history is not available due to the enrollee recently starting with the health plan.  Opioid naïve edits and morphine milligram equivalent (MME) edits are also being reviewed in audits for accuracy and to validate the claim processing is consistent with the plan’s submitted opioid safety edits and own policies.  Unlike 2021, in 2022 CMS did not focus on COVID cases during the Part D program audits.

In addition, CMS has been issuing Notices of Non-Compliance (NONC) to Sponsors for not including all required protected class of drugs on their formulary and plan finder file submissions.  This new development is causing plans to re-look at their formularies and formulary processes to ensure appropriate inclusion of protected class drugs with each submission.

BluePeak can help!

Plans should expect continued CMS scrutiny of claims and coverage determinations in the upcoming plan year through program audits, financial audits, and hoc self-audits.  Mock audits are a great way to test these highly scrutinized areas. Not only will this reduce your risk during CMS audits, but it will ensure your enrollees have the experience and access they expect during the plan year.   BluePeak’s mock audit process matches the CMS audit process and tests readiness through universe and claims review.

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