CMS Audit Annual Report Highlights Importance of Mock Audits

Imagine you are the Compliance Officer of your health plan, and you see the email from the Centers for Medicare & Medicaid Services (CMS) announcing you have been selected for a program audit. Did you take the opportunity in the months leading up to this day to confirm your organization can pull compliant universes? Did you take the time to perform some mock reviews with your Organization Determinations, Appeals, and Grievances (ODAG), Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Administration (FA), Special Needs Plan Model of Care (SNP-MOC), if applicable, and Compliance Program Effectiveness (CPE) staff to ensure they are comfortable and skilled presenters? What about your first-tier, downstream, and related entities (FDRs)? Or did you wait, thinking you had plenty of time to get this done?

In the May 8, 2018, release of the Part C and D Program Audit Annual Report (found here), CMS stated, “Mock audits will not only help you prepare for an actual CMS audit, but may help you improve your operations by identifying areas that are problematic or otherwise non-compliant with CMS regulations.”

Our clients find the Gorman Health Group mock audit services provide value by:

  • Identifying findings not known at the time of the mock audit
  • Providing recommendations on the selection of the best speakers and presenters
  • Uncovering gaps in processes, including one plan under the impression the delegate was performing a function that the delegate thought the plan was performing
  • Identifying additional FDRs
  • Determining a plan was not sending the Explanation of Benefits on a monthly basis

At Gorman Health Group, we can provide your organization with a structured mock program audit experience utilizing our industry veterans and the latest CMS audit protocols, offering a clear picture of how you might perform in a CMS program audit. The mock audit approach also allows you to begin correcting any deficiencies noted before CMS arrives. Are you ready?



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Beth Matel
Beth Matel

Beth Matel is a Senior Director of Compliance Solutions at Gorman Health Group (GHG). In this role, she has assisted health plans in developing compliant processes and corrective actions for the Centers for Medicare & Medicaid Services (CMS) in response to audit conditions and findings, directed onsite and virtual focused audits, assessed new and existing plan readiness, produced Part C and D delegation oversight programs, assisted with large-scale member/marketing material review, and created and conducted focused trainings. Beth leads a team of highly skilled senior consultants with a range in expertise that includes Appeals & Grievances, Sales & Marketing, and Compliance. Beth brings GHG clients more than 25 years of experience as a seasoned Medicare managed care compliance professional as well as a knowledgeable resource in Medicare Advantage and Part D.

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