Medicare Advantage and Part D Data Validation Audit Services

Health Solutions

October 16, 2015

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, over the last three years, 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’ overarching goal is to ensure that data is reliable, valid, complete, and comparable amongst sponsoring organizations and useful for performance measurement.

The results of these rigorous audits will have to be attested to by health plan sponsors. If results do not meet CMS specifications, the plan will be subject to enforcement, including Corrective Actions. CMS has released standards for plan sponsors in selecting a Data Validation Contractor and FTI Consulting meets these standards. We have a unique cross-functional team that has worked in Medicare Advantage and Part D since the programs’ inceptions and have the relevant Medicare Part C and Part D regulatory compliance and operations knowledge required to assist your plan with these audits. FTI Consulting has led large scale data validation projects for government contracted health plans and their business partners such as PBMs and can bring this experience to bear for your plan’s audit needs.

FTI Consulting has performed numerous “mock” audits for Medicare Advantage and Part D plan sponsors of every size and type. We have also helped plans implement ongoing monitoring and auditing programs and have conducted large scale medical and pharmacy claims, enrollment, appeal and grievance, and PDE reconciliation reviews. FTI Consulting has also performed delegated entity reviews that have given us unique visibility into many of the areas that will be reviewed in a Data Validation Audit.

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