CMS Audit preparation is not something that can be crammed for at the last minute and expect good results. If health plans aren’t constantly checking all CMS guidelines and updates for compliance concerns, not only will inaccuracies slip into regulatory compliance tables, but they will also reveal how member care isn’t being prioritized. Keep in mind that CMS isn’t aiming for perfection. They undertake these evaluations to see whether or not the commitment to member care is accepted daily. After all, CMS laws are in place to protect members, not health plans.
With this in mind, health plans should consider the following before getting a CMS Program Audit notice:
- Have you lately conducted a risk assessment?
- Have you gone through the FWA and Code of Conduct training?
- Have you checked your Policies and Procedures to verify they are under the most recent CMS guidelines?
- Have you made the SNP-MOC changes?
- Have you put AIP Letters into action?
- Have you revised the Notice of Medicare Prescription Drug Coverage Denial?
- Are you receiving regular updates from your FDRs and assessing them to ensure compliance with CMS requirements?
If you answered yes to these questions, you are now ready to carry out the CMS audit preparatory game plan.
Create Audit Playbook
To begin, you need to draft an audit playbook. Using an audit playbook allows a strategy to assist auditors in understanding exactly how each automated process performs and how choices are made.
This plan should include a detailed breakdown of how each task corresponds to your internal plan policies and the applicable compliance standards. You may start developing your audit playbook if you have improved insight into compliance procedures and the capacity to evaluate and manage transactions at a comprehensive level.
Audit Playbook Elements
The audit playbook includes all strategies for obtaining data and incorporating it into the reports required by auditors. It should cover your present administrative rules and procedures for key decision-making processes. This enables you and regulators to guarantee that the correct data is collated and utilized to evaluate compliance – something that may be surprisingly difficult to get right in some cases, particularly when time-sensitive information is conveyed through numerous checkpoints.
However, the capacity to track each data element via all touchpoints is critical for showing that a health plan is adhering to relevant rules and regulations. Keeping an organized, thorough playbook of these paths, regulations, and decision trees may assist remove misunderstandings, highlighting needed adjustments, and guaranteeing a smooth and effective audit. Essentially, this effort will streamline your auditing process.
Exercise Mock Audits
The following are the primary advantages of organizing mock audits regularly:
- Gain constant visibility into administrative procedures, member relationships, and clinical choices.
- Ensure CMS audit preparedness, even at the last minute.
Audit Engagement and Universe Submission
What steps can health plans take to prepare for audit engagement and universe submission?
- Audit Engagement: Now is the moment to mobilize internal and external resources because health plans must notify CMS of any noncompliance problems within five business days after receiving an engagement letter.
- Universe Submission: The capacity of a health plan to generate clean universes is crucial to CMS compliance since you only have 15 days and three chances to do it correctly.
(Note: If you’ve been creating and reviewing universes routinely, you’d be ahead of the game.)
Audit Field Work
What should health plans do in the field during audits?
CPE Audit: A CPE audit can be done on-site or via webinar, with sample choices gathered around two weeks before the CPE entry conference — and, for SNP-MOC, on the Thursday before the entrance conference — thus, health plans should complete a tracer review for each audit.
(Note: While this seems like extra work, keep in mind it can be simpler to perform tracer reviews when the particulars of an audit or monitoring are fresh, as opposed to going back months later and scrambling to put this together.)
HPMS Memo: You can also be asked to do a tracer for an HPMS memo. Ensure you keep clear information concerning how you communicated these, including the responses and any documentation supporting it.
Audit Reporting
What should health plans do to prepare for audit reporting?
Condition Classification and Audit Scoring: Before getting the preliminary audit report, you should have a fair idea of the probable audit findings, so start working on those areas before you get the formal notification.
Draft Audit Report: A draft audit report will be prepared within 60 days of the Exit Interview, and your plan’s response to the Draft Audit Report will be provided within 10 business days.
Final Audit Report: Plan your response to the Corrective Action Request (CAR) with Corrective Action Plans (CAPs) within seven days of receiving the final audit report.
Post-audit Activity
If you approach CMS Program Audits with a desire to ensure operational health, these processes never really end. Yes, the actual audit may conclude, and if everything goes well, you may receive a few observations — and perhaps a CAR — but hopefully no ICARs.
However, health plans need to monitor their compliance activities continuously.
This is where RCM Matter can make your life simpler. We know the world of Medicare, Medicaid, and commercial health plans from decades of hands-on Audit & Monitoring department oversight. Our integrated Audit & Monitoring package helps you instill compliance within your culture and make it a way of life. We help ensure your health plan sustains audit readiness at all times. Audit preparation.