Highlights of Proposed 2020 Audit Protocols

The Centers for Medicare & Medicaid Services (CMS) released an HPMS memo on August 20, 2019 providing an overview of the upcoming changes to program audits through 2021.  These changes are out for a 60-day comment period with comments being requested by October 15, 2019. These changes will supersede the proposed changes shared on April 2, 2018.   Here are the highlights:

  • CMS will continue to use the same audit protocols and record layouts for universes in 2020that were used in 2017, 2018 and 2019.
  • CMS is reducing the volume of information that must be submitted in audit year 2020. Here are the highlights of the proposed changes:
    • CPE-CMS clarified that if the audit review period crosses calendar years that requested documents (i.e. risk assessments) would need to be provided for both years within the audit period. CMS also removed references to allowing data in the csv format and made updates to the universes for FTEAM and ECT.
    • FA-Updated verbiage to remove references to DMRs as they are not part of the FA process. Updated verbiage that the 30 cases pulled for FA will not follow the prior numeric break down.  In the Transition section, the number of samples has been increased from 15 to 30 samples.   Removed references to HICN and replaced with MBI.  The Website review has also been removed.
    • CDAG-Updates were made to the Guidelines to remove references to Tables 9,10 and 16. Updated Table 7 to clarify the compliance standard is no later than 14 days, instead of 7.  In the Timeliness section updated samples from 75 to 65 due to removal of Tables 9 and 10.  Samples for Grievances were updated from 10 to 20 due to the removal of Call Logs.  Exclusion Language was added to Tables 1-8, 14 and 15 to state “Exclude requests that require an AOR (or other conforming instrument) but the AOR has not been receive as of the date of the universe submission”.
    • ODAG-Removed references to Call Logs (Table 14) and dismissals. Updated Table 3 to show the compliance standard as 95% in 30 days for clean claims and 60 days for unclean all other claims from non-contracted providers. Timeliness section was updated to remove dismissals and changes samples from 65 to 60.  In Clinical Decision Making (CDM), the approved organization determination cases were removed, updating the samples in this section from 40 to 35.  Within CMD, the following processing requirements were removed: 3.2.7, 3.2.8 and 3.2.10.  In the Grievance section, samples were updated from 10 to 20 due to the removal of Call Logs.  For Tables 1,2,4,5,6 and 11, added the following exclusion language: “Exclude requests that require an AOR (or other conforming instrument) but the AOR has not been received as of the date of the universe submission; and Exclude requests for extensions of previously approved services, concurrent review for inpatient hospital and SNF services, post service reviews, and notifications of admissions”.  For Tables 3,7,8,9 and 10, added the following exclusion language: “Exclude requests for extensions of previously approved services, concurrent review for inpatient hospital and SNF services, post-service reviews, and notifications of admissions”. Table 12 added the following exclusion language: “Exclude requests that require an AOR (or other conforming instrument) but the AOR has not been received as of the date of the universe submission”.
    • SNP-MOC-. Removed the audit element for enrollment verification. In the Care Coordination section, the compliance standards have been simplified.

Want to help ensure your Plan is ready for a 2020 Program Audit?

BluePeak Advisors can help!  We can perform operational assessments and/or mock audits of your Plan’s operations to detect areas requiring corrective action, help your Plan define and implement effective corrective actions where necessary, and assist your Plan with developing a prevention plan of ongoing monitoring and auditing to help minimize the ongoing risks of non-compliance.  Contact us today at (469) 319-1228 or info@bluepeak.com