Feeling the Madness! The 2020 CMS Program Audit Cycle Begins

This March, sports will not be the only excitement—health plans are gearing up to receive audit notices as we enter the second year of the four-year Program Audit Cycle. The ball is in your court… Your team’s readiness depends on review of the current audit protocols and practice, practice, practice. Are you performing “mock” auditing to identify risks?

The Centers for Medicare and Medicaid Services (CMS) started the current audit cycle in 2019 with a number of audit changes and process improvements to assist plans, including:

  • Removal of Audit Element Review: Suspension of the review of Call Logs and the Website audit element from the Formulary and Benefit Administration protocol, as well as removal of the Enrollment Verification audit element from the Special Needs Plans Model of Care (SNP MOC) protocol.
  • Streamlining Information: Release of the Program Process Overview document with the Program Audit Validation and Close Out guidance, along with a Program Audit Frequently Asked Questions (FAQs) on the CMS program audit website.
  • Compliance Program Effectiveness (CPE) Protocol Changes: Includes suspension of the CPE self-assessment questionnaire and several changes to the CPE universes.

CMS is continually seeking “…to improve audits by soliciting sponsor feedback,” and recently opened for comment on the proposed changes for 2020. Some notable changes include reductions in audit elements and protocols, such as:

  • Removal of Part D Coverage Determinations, Appeals, and Grievances (CDAG) Table 9 (Standard Independent Review Entity [IRE] Auto-Forwarded Coverage Determinations and Redeterminations [SIRE]) and Table 10 (Expedited IRE Auto-Forwarded Coverage Determinations and Redeterminations [EIRE]), as well as removing Table 16 Call Logs.
  • Reducing timeliness CDAG sample size from 75 to 65 and increasing Grievances from 10 samples to 20, likely to compensate for the removal of Table 16 Call Logs.
  • Edits to the CDAG universe requirements, including updating the notification requirements to coincide with Parts C and D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance Section 10.5.3 and adding exclusion language throughout the remaining tables.
  • Removal of ODAG Table 14 Call Logs and reducing timeliness samples from 65 to 60 cases and Clinical Decision-Making from 40 to 35, while also increasing Grievance samples from 10 to 20.

The industry anxiously awaits the distribution of the updates, as the current audit protocols are set to expire April 30, 2020.


GHG assists plans with implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

Anita Green
Anita Green

Senior Director, Compliance Solutions

Anita Green is Senior Director of Compliance Solutions at Gorman Health Group (GHG). Anita is a Registered Nurse with more than 30 years of health care experience, beginning her healthcare career in the U.S. Air Force. Anita has functioned in the role of hospital administrator for a 200+ bed hospital, also serving as a member of the senior leadership team and director of risk management with oversight accountability of patient advocacy, hospital security, and provider credentialing. Her clinical experience includes (but is not limited to) critical care nursing in both military and civilian settings, case management, utilization review, discharge planning and diabetic nurse education. Anita is a former Compliance and Privacy Officer for a multi-state Medicare Advantage Prescription Drug health plan, and in that role she supported new Medicare Advantage applications, service area expansions, CMS and Department of Insurance audits, transitions to new pharmacy benefit managers, systems implementation, and sales and marketing oversight. In her consultant capacity Anita has stepped in as interim Compliance Officer for several organizations and is comfortable providing compliance support and leadership to all operational aspects of managed care. Anita holds a BSN from University of Texas Health Science Center in San Antonio, and a Juris Doctor from St. Mary’s University School of Law.

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