The Medicare Parts C and D Oversight and Enforcement Group (MOEG) is responsible for creating and administering the audit strategy to oversee programs under the Department of Audit Operations in the Centers for Medicare & Medicaid Services (CMS).
MOEG conducts audits of participating Sponsoring organizations (Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs) and Section 1876 Cost Plans) to evaluate the adherence to contractual and regulatory requirements by CMS, particularly, requirements associated with access to medical services and drugs to ensure Medicare beneficiaries receive services appropriately.
CMS gathers feedback on the audit process from industry stakeholders on an annual basis, with the purpose of improving routine audit operations and expanding new areas that may require oversight. Recently, CMS released an updated program audit process that outlines the expectations placed on Medicare Parts C and D oversight, process alignment, and organizational accountability.
The updated program audit process is structured into four phases as follows:
- Audit Engagement and Universe Submission begin with CMS sending an engagement letter via the Health Plan Management System (HPMS) to a Sponsoring organization that defines audit scope, timelines, and instructions for submission of requested data and supplemental documentation.
- Audit Field Work during this phase is usually conducted over a period of two weeks. CMS and the Sponsoring organization align objectives and logistics, then data and supporting documentation are submitted as requested. CMS issues a preliminary draft report and reviews findings with the Sponsoring organization.
- Audit Reporting formalizes findings of noncompliance classification of audit conditions. It begins at the conclusion of audit filed work with a preliminary draft report. Audit conditions are classified as:
- Observation – findings that don’t require submission of a corrective action plan.
- Corrective Action Required – significant findings that require correction to strength internal controls and prevent future noncompliance.
- and Invalid Data Submission when a Sponsoring organization has failed to produce an accurate or complete universe and/or documentation to CMS.
- Audit Validation and Close Up is the final phase and ensures that corrective action plans address noncompliance. It occurs over a period lasting up to six months or longer, and Sponsoring organizations have an opportunity to demonstrate to CMS that the noncompliance findings have been corrected during the program
How the CMS Audit Strategy of Medicare Parts C and D Programs May Impact Providers
Healthcare providers are not audited by this CMS program. However, providers are operationally connected to audited functions and to audit requirements placed on Sponsoring organizations, which results in measurable indirect impacts on provider’s administrative and compliance activities.
- Providers generate a significant portion of the data contained in all requested universes that CMS audits require Sponsoring organizations to submit. These universes represent complete sets of records, such as claims, coverage determinations, appeals, and payment-related data. Sponsoring organizations must submit this data within 15 business days of the engagement letter and may also require providers to supply additional documentation or assist with data validation and reconciliation.
- When CMS identifies noncompliance, Sponsoring organizations must submit an impact analysis for affected Medicare beneficiaries which requires tracking back operational sources. Providers might be identified as a source of delayed, incomplete, or inaccurate information.
- CMS requires Sponsoring organizations to submit Corrective Action Plans (CAPs) within 30 days from the issuance of the final audit report that will prevent recurrence. The CAPs may include updates in, for example, authorization and claims submission workflows and timelines along with documentation standards.
- When audit findings are significant, CMS may refer to enforcement actions against Sponsoring organizations with additional monitoring requirements. The Sponsoring organizations may increase provider audits, implement more frequent reporting, and operational controls impacting provider daily interactions.
Providers Audit Support and Responsiveness
To minimize disruptions and maintain compliance during CMS audits, providers may benefit from adopting proactive strategies that align with Sponsoring organizations’ requirements. This includes:
- Educating Staff: Ensure clinical and administrative staff are knowledgeable of documentation requirements, records retention, and claims submission rules pertaining to Sponsoring organizations; Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and Section 1876 Cost Plans.
- Establishing Clear Points of Contact: Designate a responsible individual for the Sponsoring organizations’ audit-related inquiries or validations and establish a process to retrieve historical records for sampled cases.
- Collaborating on Corrective Actions: Take a cooperative approach in supporting Sponsoring organizations’ corrective action plans to identify process gaps affecting Medicare beneficiaries.
- Engaging in Ongoing Education: Participate in administrative and provider education initiated by Sponsoring organizations.
- Windham Brannon’s Healthcare Consulting Practice can assist you with implementing CMS regulatory documentation changes and responding to audit-specific programs, enabling your organization to stay informed and compliant.
For questions or more information, contact your Windham Brannon advisor today, or reach out to Denise Gaulin.
