CMS Program Audit Prep: Leveraging Your Appeals & Grievances Software

Happy New Year and ‘tis the season for CMS Program Audits!  In the 2024 CMS Program Audit Updates memo released on December 19, 2023, CMS confirmed their plans to conduct both routine and focused audits of health plans in 2024. The new focused audits will assess compliance with the coverage and utilization management (UM) requirements finalized…

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2024 Oversight Activities – Utilization Management Changes

CMS notified Medicare Advantage Organizations (MAOs) on October 24, 2023, that it will be conducting strategic conversations on the new Utilization Management (UM) requirements effective January 1, 2024. Following these conversations, CMS will start conducting routine and focused audits of the new prior authorization and related rules published in April of this year in the…

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CMS Audits – Be Prepared to Avoid These Common Findings

As the 2022 Program Audit Cycle winds up with the last of the routine audit engagement letters issued in July, we are starting to see the audit results. This year saw new audit protocols, and some plans struggled with the new universe layouts. In addition, CMS added a new observation classification – ORCAs (Observation Requiring…

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Provider Directory Accuracy—Why is it Important?

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to post an online provider directory that is up-to-date and accurate. Beneficiaries must be able to use the online provider directory to find contracted providers they can see to receive covered services. Inaccurate provider directories pose risks to beneficiaries. Because members rely on…

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Are You Prepared for Your Next CMS Program Audit?

Preparation is critical to produce accurate universes and achieve successful CMS Program Audit results. In November 2021, CMS announced they will send program audit engagement letters to sponsors, starting in February through July 2022. If you ask yourself when should your readiness for a program audit begin? The answer is NOW! CMS made several significant…

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CMS Program Audits – Preparation Is Critical

Comprehensive preparation is critical to producing accurate universes and achieving a successful CMS Program Audit. Madena’s experts have dozens of years of experience and can help Part C and D plans with all aspects of the Audit process. How Madena Can Help With Your CMS Program Audit Development and implementation support of universe design – we…

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Medicare Part C and D Data Validation Audit

Medicare Part C and D Data Validation Audits (DVA) are required by the regulations (42 CFR 422,516, 422.514, CMS-4085-F) implemented by the Centers for Medicare and Medicare Services (CMS). In order to ensure the independence of the Data Validation Audit, organizations cannot use their own staff to conduct it. Instead, Medicare Advantage Organizations (MAO) and…

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Independent Validation Audits

What’s Possible After a Program Audit? by Sue Dahlkamp, Interim Compliance Officer & Senior Consultant CMS requires that sponsoring organizations undergo an Independent Validation Audit (IVA) if they receive a number of ICARs or CARs on their Program Audit to demonstrate correction of all reported audit conditions. CMS then determines when the audit can be…

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