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 UpdatesProgram Audit 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 in CMS-4201-F.

For the past few years, CMS program audits have been kicked off in February, however this year CMS has announced they will begin sending engagement letters for the focused audits starting in January 2024.

Program audits will continue to include the previous applicable program areas but will target the new UM requirements during the Part C Organization Determinations, Appeals, and Grievances (ODAG) review, as well as the Compliance Program Effectiveness (CPE) review.

The UM-focused audits will be conducted on plans who do not have routine scheduled audit for 2024. The audit will be limited to ODAG and CPE and will specifically target compliance with the coverage and UM policies in CMS-4201-F.

  • Have you leveraged your appeals data to confirm you’re prepared for the new 2024 UM audits?
  • Is your Appeals & Grievances (A&G) process aligned to catch mistakes with the original organization determination/UM process?
  • Are you following the same guidelines upon appeal to ensure your organization is aligned with CMS’ requirements?
  • Does your A&G system auto confirm that you have documented in the case file your LCD/NCD and clinical criteria guidelines? Are they readily available?
  • Can you easily download your universes and review your case files in one click with no manipulation needed?

If the thought of this new process triggered any anxiety, caused a lack of confidence, or you felt uneasy; Cody Consulting can eradicate those feelings with our A&G software and consulting services.

We’re Here to Help

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

About us: Founded in 2006, CODY® is an Industry leader in Governance, Risk, and Compliance (GRC) Solutions designed exclusively for health plans. We enable over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico to mitigate compliance risk, maximize efficiencies, and improve outcomes. Our Enterprise technology and innovative solutions reduce administrative costs, increase accuracy, ensure regulatory compliance, and provide a better experience for plan members and providers.