CMS Audit Updates—Proactive Steps to Ensure Readiness & Maintain Compliance

Program AuditSuccess in any CMS audit depends on being prepared to ensure readiness and maintain compliance throughout the year. Taking proactive steps now to support future CMS audits will produce better results and experiences for health plans and create a greater level of confidence for participants.

New Audit Protocols for CY2022

Earlier this year, CMS released the final Medicare Advantage Prescription Drug (MAPD) Program Audit Protocols for CY2022. Several significant changes within the protocols should be analyzed and addressed in each organization. Now is the time to take an in-depth look at the changes to ensure readiness for next year. Consider taking these steps today:

  • Review universe and record layout changes and update internal reporting to capture new layouts
  • Review compliance standards and newly added methods of evaluation to ensure appropriate processes and documentation support compliance
  • Review and update your audit playbook, including internal and first tier, downstream and related entity audit participants
  • Pull and test universes for accuracy
  • Perform mock audits to test your preparedness; identify and correct any risk areas
  • Identify and resolve areas that may need additional clarification
  • Attend CMS’ audit protocol reviews scheduled in August or listen to the recordings to be posted at Upcoming/Current Events | CMS

New Program Integrity Audit for CY2021

In May 2021, CMS announced its collaboration with the Plan Program Integrity Medicare Drug Contractor (PPI MEDIC) to initiate Program Integrity Audits for CY2021. These audits will evaluate the plan’s efforts to prevent, detect, and correct fraud, waste, and abuse (FWA) by reviewing the following areas:

  • Identification and prioritization of FWA risks
  • FWA monitoring and auditing
  • Effective compliance with statutory and regulatory requirements, guidance, and direction
  • FWA complaints, investigations, referrals, and requests for information
  • Proactive FWA initiatives

Review your current FWA program using the outlined scope above to help identify potential gaps in your activities and oversight structure and build a more effective program.

We’re Here to Help

CODY® team of compliance and operational consultants have years of experience in day-to-day health plan operations, CMS audits, and oversight activities. We’re here to support you, or we can do it for you. We help create and implement audit-ready reporting and operations and perform universe validation and audits that target potential high-risk areas. We also provide compliance support to develop and implement activities and structures to build and maintain an effective compliance program.

CodySoft®, our proprietary software, is developed exclusively for health plans to enhance operations, increase efficiencies, and help ensure regulatory compliance. Below are modules from our compliance suite, created to help plans work smarter, not harder:

  • Appeals and Grievances Module®—AG automates workflows to increase efficiency and reduce compliance risk. Required information is captured upfront to decrease backend work, allowing more time for QA rather than data gathering.
  • HPMS Memo Module®—streamlines the entire management process from memo intake, distribution, and review to response and reporting.
  • Compliance Correspondence Module®—CC is a management tool built to organize the entire correspondence distribution, review, and monitoring process. Complementary to the HPMS Memo Module®, CC reduces compliance risk through an integrated workflow.
  • Policy and Procedures Module®—streamlines the entire lifecycle of a health plan’s policies & procedures—from creation, approval, distribution, comprehension, and certification.
  • Incident Management Module®—IM is a full-cycle tool developed to proactively manage incidents from identifying trends and addressing the root cause to reporting and final resolution.
  • Regulatory Analyzer®—RA centralizes all rules & regulations in one location for easy access. Locate and crosswalk important federal & state regulatory content to ensure compliance of all collateral—member materials, policy & procedures, codes of conduct, employee handbooks, contracts, and more.
  • Risk Management Module®—RM assesses and tracks the effectiveness of a compliance program to address challenges in today’s ever-changing regulatory environment.

To find out how CODY® can help your plan ensure audit readiness and maintain compliance, contact us today for a consultation or a software demo.

About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft®, our proprietary suite of software, is designed specifically for health plans.