CMS is intensifying its practice of auditing Medicare Advantage (MA) and Prescription Drug Plans (PDPs) for compliance with the many CMS requirements and specifications outlined in the agency’s Audit Guides. All MA organizations and Part D sponsors are required to provide for internal monitoring and auditing, including a risk assessment process to identify and analyze risks associated with failure to comply with all applicable Medicare Advantage compliance standards, as part of their compliance plan.

Using an external (third-party) audit process can help your organization detect potential areas of non-compliance early, correct any risk areas, and protect your organization from possible federal sanctions. As the leader in Medicare regulatory compliance, Gorman Health Group is pleased to offer our COMPASS™ Mock CMS Audit Service.

COMPASS™ Mock CMS Audit Service provides MA plans, MA-PDs, and PDPs with an indication of how your organization would likely perform in an actual CMS audit, as well as how your organization is able to document compliance with the audit guide elements. The GHG auditors use the regulations stipulated at 42 CFR 422 and 423, as well as CMS guidance located in the Medicare Managed Care Manual and the Prescription Drug Benefit Manual.

Our mock audits are highly structured events designed to accurately duplicate the CMS audit process. We begin by sending confirmation letter with requests for "universe" lists and available documentation, which we review off site. We then conduct the on-site review of samples and interviews and present a preliminary findings report on the last day of the on-site audit. Within four weeks, a detailed report of findings and recommendations is issued, detailing areas where your organization may be at risk of non-compliance, as well as industry best practices.

A CMS mock audit includes:

• A detailed audit to analyze health plan or prescription drug plan operations based on the elements outlined in the CMS Part D and Part C audit guides and other associated CMS guidance.  We can also perform a review of only those requirements delegated to a PBM, such as redeterminations and exceptions.
• Hundreds of plan sample case files, policies and procedures and other plan materials are also reviewed for compliance.
• Deployment of GHG Senior Consultants with Medicare managed care auditing expertise to conduct the CMS mock audit review process, including interviewing appropriate staff and reviewing sample files and all required documentation, including policies and procedures, workflows, and other documents, to determine compliance with the regulations.
• Preparation and delivery of a detailed, standardized report which clearly shows each CMS element reviewed alongside the specific CMS requirement associated with each element. The report shows how these elements are met or not met, along with clear-cut corrective action recommendations.

 

Click here to see a list of available mock CMS audits.

 

For more information, contact email us at
compass@gormanhealthgroup.com or call us at 202-364-8283.