Medicare Advantage and Part D Data Validation Audit Services
September 5, 2011
Medicare Advantage and Part D plan sponsors have long been subjected to extensive auditing and monitoring standards set forth by the Centers for Medicare and Medicaid Services (CMS). However, CMS has recently shifted their health plan oversight strategy from focusing on retrospective case file audits to more proactive data monitoring.
In order for CMS to carry out this proactive monitoring strategy, it is requiring Medicare Advantage and Part D plan sponsors to contract with qualified independent third parties to conduct prescribed Data Validation Audits. These audits will require delving more deeply than ever into a plan sponsors’ data systems and their ability for proper data storage and reporting in order to test the data’s validity and reliability as it relates to CMS mandated reporting measures. Another complicating factor in executing Data Validation Audits is the concept of delegation of administrative and clinical functions such as medical and pharmacy claims payment to Pharmacy Benefit Managers (PBMs) and other entities. CMS’s overarching goal is to ensure that data is reliable, valid, complete, and comparable amongst sponsoring organizations and useful for performance measurement.