If The Centers for Medicare and Medicaid Services (CMS) walked through your door today and asked to audit your health plan, would you be prepared? Unfortunately, for many Medicare Advantage and prescription drug plans, the answer is “no.” Yet, with CMS continuing to crack down on compliance violations, this hypothetical audit could very well become a reality.

With Annual Enrollment Period (AEP) material preparations now in the critical final stages, the timing of these audits could be particularly bad for health plans that are not prepared. To manage the audit, they would need to pull crucial resources from compliance departments, increasing the risk of falling behind on AEP materials. This could delay distribution of important member materials, putting your plan at risk of incurring additional compliance violations and hefty fines.

Because being audited during this crucial season is never ideal, it’s important plans can effectively manage both projects, if needed. One way to prepare for an impromptu audit is to conduct a mock audit that identifies weaknesses and potential compliance violations.

This should include a thorough review of all areas under CMS’ compliance program policies:

1. Written policies, procedures and standards of conduct

2. Compliance officer, compliance committee and governing body

3. Effective training and education

4. Effective lines of communication

5. Effective systems for routine monitoring and auditing

6. Systems and procedures for promptly responding to compliance issues

7. Sponsor oversight and accountability of first-tier, downstream and related entities

More information on these can be found under Chapter 9 of the Medicare Prescription Drug Benefit Manual and/or Chapter 21 of the Medicare Managed Care Manual.

Under our consulting services, Cody’s team of compliance experts can also conduct compliance audits and CMS mock audits to ensure all standards are met and your health plan is prepared, should an unexpected audit occur. Contact us today to learn more.