As Plans Continue to Struggle with the Same Common Conditions, CMS Makes Few Changes from the 2017 to 2018 Audit Protocols
As the Centers for Medicare and Medicaid Services (CMS) begins sending program audit engagement letters this month, plans may have noticed changes from the 2017 to 2018 protocols are minimal. As CMS enters the last year of this audit cycle (2015-2018), plans continue to struggle with the same common conditions these protocols were designed to identify.
Changes from the 2017 to 2018 CMS program audit protocols include:
- Call Log submissions for Coverage Determinations, Appeals and Grievances (CDAG) and Organization Determinations, Appeals and Grievances (ODAG) have been reduced and are now based on a plan’s enrollment:
- Less than 50,000 enrollees – 10 days of calls
- 50,000 – 249,000 enrollees – 7 days of calls
- 250,000 or more enrollees – 3 days of calls
- Medicare-Medicaid Plans (MMPs) – 10 days of calls, regardless of enrollment
- Field work, which includes the operational audit webinars and onsite Compliance Program Effectiveness (CPE) audit, has been extended to 3 weeks to allow an additional week for plans to prepare for the CPE audit on Week 3. Operational audits, such as ODAG, CDAG, Formulary Administration (FA) and Special Needs Plan-Model of Care (SNP-MOC) will still occur during Week 1. If a plan has five or more audit areas, which usually includes applicable MMP audit areas, then those areas are covered during Week 2.
- The Medication Therapy Management (MTM) program area pilot has been removed from the 2018 CMS Program audits. CMS is reviewing data gathered from the previous two years, so plans should continue to monitor their MTM processes, in the likely event that this area resurfaces in future program audits.
- The MMP audit has moved from pilot to fully operational and includes the Service Authorization Requests, Appeals and Grievances (SARAG) and Care Coordination Quality Improvement Program Effectiveness (CCQIPE) audit areas.
CMS will send 2018 program audit engagement letters through September. Plans should be aware that CMS can send targeted audit engagement letters at any time. BluePeak has observed plans receiving engagement letters for ODAG, CDAG and FA in October and November.
BluePeak has worked with over 120 health plans and most of the top PBMs. Since 2013, BluePeak has conducted over 150 CMS mock audits and onsite support projects for clients undergoing actual CMS program audits. Our mock audits follow the CMS audit protocols, including the recent changes above. Contact us today for a free consultation.