Posts Tagged ‘audit’
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…
Read MoreAEP Enrollment Processing Tips—Do’s & Don’ts from End-to-End (E2E)
How well your organization handles a new enrollment during the Annual Enrollment Period (AEP) generally sets the tone for the upcoming contract year for you and your new member. Beginning with Sales and flowing to Enrollment Operations—it’s critical to understand specific actions that trigger reconciliation challenges and member abrasion. With CMS shifting the weight of…
Read MoreCMS Audit Updates—Proactive Steps to Ensure Readiness & Maintain Compliance
Success 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…
Read MoreHow to Mitigate Compliance Risk & Improve Operations—An A-to-Z Approach
As the Centers for Medicare and Medicaid Services (CMS) increases its scrutiny and escalates enforcement, Compliance managers are on guard to ensure regulatory standards are met—and fines, sanctions, or even termination from CMS programs, are avoided. How can Compliance and Operations managers mitigate compliance risk and improve operations? The best way to avoid compliance errors…
Read MoreAre Your Policies and Procedures Audit-Ready?
Policies and procedures are essential tools for any organization. By clearly articulating the requirements established by external oversight bodies and internal standards, they are an effective control to support consistency, accountability, and compliance. To be effective, policies and procedures should be: Designed as tools that help employees make decisions related to their assigned tasks/responsibilities; Clear,…
Read MoreMedicare 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…
Read MoreIndependent 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…
Read More