Medicare Advantage and Part D “Mock” CMS Program Audit Services

Health Solutions

October 16, 2015

While the Centers for Medicare and Medicaid Services (CMS) has continued to increase the amount, complexity, and breadth of audits for Medicare Advantage and Part D plans. FTI Consulting has had unique visibility into CMS audits and investigation protocols and can assist Medicare Advantage and Part D plans in preparing themselves for the likelihood of a CMS visit.

CMS has dramatically changed its audit protocols by relying on the large amounts of data submitted by Medicare Advantage (MA) and Part D plans and is employing a risk-based audit plan. As a result of this approach, CMS has stated that plans have access to the same types of information related to their performance as CMS. Therefore, plans are expected to have proactively identified issues and be focused on remediation steps. CMS has also made a strong connection between operational performance against Medicare requirements as an indicator of compliance program effectiveness.

MA and Part D plans may be subjected to any of the following audits, often simultaneously:

  • Compliance and Program Audits: including Compliance Program Effectiveness (CPE) and Program Audits with a focus on key operational performance areas such as: compliance plan and fraud, waste, and abuse; formulary and benefit administration; transition fills; organization and coverage determinations; appeals and grievances; outbound enrollment verification; and SNP Model of Care.
  • Financial or Payment Related Audits: Risk Adjustment Data Validation (RADV) audits; bid audits; Data Validation audits (DVA); and One-Third Financial audits including PDE.

Both groupings of audits are also folded into CMS’ past performance review protocols whereby a MA or Part D plan’s ability to remain a CMS contractor or expand into new services may be halted based on past audit performance. CMS has also stated that plans with compliance issues will have their plan’s STAR ratings severely impacted.

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