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Financial Audits: Lessons Learned

By September 9, 2019September 16th, 2019CMS, PDE

Financial audits are just one of the many types of Medicare Part D audits.  Financial audit frequency and awareness continues to increase, and plans are realizing that they must integrate more robust monitoring and oversight to mitigate their compliance risk during these audits.  Focusing on the following three specific areas will not only reduce compliance risk during a financial audit, but also provide valuable feedback into how claims are being processed and reported into CMS:

  1. PDE Accuracy– Analyze PDE records to validate PDE financial fields are being accurately calculated and beneficiaries are appropriately advancing through all Medicare benefit phases.  Review beneficiary utilization patterns and question any inappropriate situations where there may be an inappropriate duplicate prescription.
  2. Benefit Administration– Validate CMS approved benefits are being appropriately applied and all CMS rules and regulations are being followed.  Review complex situations where the beneficiary crosses over more than one benefit phase.  Ensure Medicare Secondary Payer (MSP) claims are processing appropriately and any retroactive coordination of benefits (COB) situations are addressed.
  3. Rebate Management– Compare rebate amounts with submitted PDE data to identify situations where the rebate amount does not correlate with the claim amount.  Analyze prior year’s rebate information with the current year to identify unexpected rebate differences between plan years.

By focusing on the three areas above, plans will be able to increase their monitoring and oversight over PDE records, claim processing, and rebate management.  Additionally, it is not uncommon that plans may find additional revenue opportunities within their PDE data to optimize their financial reconciliation amount.  BluePeak has a history of supporting plans in all three areas and can help plans by performing an audit, completing a gap and readiness assessment, or providing education to your internal teams to build and enhance each area.

Contact us today if you have any questions our would like to discuss some options that will work best for you and your organization.

Based on the CMS audit report,

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of the non-compliance referrals were due to findings from financial audits.

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