CMS Program Audit Frequently Asked Questions – What Did We Learn?

On February 8, 2019, the Centers for Medicare & Medicaid Services (CMS) published its Audit Program Frequently Asked Questions (FAQs) document. Until now, CMS did not share key questions and answers with the general public. CMS has shifted its approach in hopes it will benefit the industry and improve the audit process.

In some cases, CMS simply reiterated what it had previously published in its December 4, 2018, “2019 Program Audit” memo or what we know organizations have already been doing, but there were new clarifications as well, some of which are discussed below.

General Audit and Validation

CMS indicates although it typically audits Sponsors once per audit cycle (an audit cycle has historically lasted three to five years), it may audit them more frequently based on risk or audit referral. This is a great reminder to always be audit ready – just because you have had an audit recently doesn’t mean CMS won’t come knocking, particularly if your organization has known performance issues.

CMS also offered a few general tips for preparing universe submissions which, as a matter of course, include providing them accurately and timely. CMS clarified that organizations populating columns with “NA” should populate the column as such (i.e., not “N/A”, etc.) and ensure all columns are populated. They recommend directing any universe questions that arise during an audit to the area Team Lead before submitting the universe. Gorman Health Group (GHG) reminds all Sponsors to incorporate these universes in your monitoring and auditing activities to ensure a successful submission process during a program audit.

CMS also specified, for independent validation audit (IVA) purposes, they require IVA vendors to use the same level of clinician that the sponsoring organization used (or was required to use) to evaluate the request or appeal. If you will be undergoing an IVA, make sure your vendor has the appropriate level of clinician available to participate.

Compliance Program Effectiveness (CPE)

CMS offered a bit more information than it provided in its 2019 Program Audit memo in relation to how call center classification and processing will be evaluated. Specifically, CMS indicated a sponsoring organization should be prepared to discuss its oversight of incoming calls (e.g., those calls previously collected via the Part C and Part D Call Log record layouts) to ensure calls are properly classified, routed, and processed. Additionally, although CMS stated several times throughout its FAQs the collection of call log data is suspended for 2019, CMS provided responses regarding how to populate call log universes. To reiterate what we stated in our previous 2019 Audit Protocol blog[, Compliance Departments should consider adding call log auditing and monitoring activities to your work plan and have a documented oversight process in place.  

CMS offered general clarifications for populating CPE record layouts, including how to list an issue that involves both compliance and fraud, waste, and abuse (FWA). CMS specified in situations where the activity can be both compliance and FWA related, sponsoring organizations should list “FWA” in the record layout and will be given an opportunity to explain to the audit team which issues are related to both compliance and FWA during CMS’ universe validation process.

Part D Formulary and Benefit Administration (FA)

With respect to the FA record layouts, CMS clarified that either the Medicare Beneficiary Identifier (MBI) or Health Insurance Claim Number (HICN) may be populated for those record layouts currently requiring submission of a HICN. Additionally, CMS responded to many questions relating to population of the NDC field. With respect to the New Member (NM) record layout, CMS indicated it should be populated to include only enrollees for which the sponsoring organization does not utilize prior claims history. Therefore, if a sponsoring organization has the claims history from the most recent plan benefit package (PBP), they may be able to determine new versus ongoing therapy, which will dictate whether or not the enrollee should be placed in the NM record layout. This may require sponsoring organizations to “scrub” their NM universe to ensure appropriate data is included. 

Part D Coverage Determinations, Appeals, and Grievances (CDAG) 

CMS reiterated coverage requests that were denied/rejected as a result of a provider being on the Preclusion List are not coverage determinations and should be excluded from the CDAG universe. However, if the enrollee contacts the sponsoring organization to find another provider to furnish the services, CMS would expect to see that coverage request in the data.

Also, CMS indicated if a live online “chat” involved a complaint or coverage request, CMS would expect to see a resultant case in the applicable universe(s). Sponsoring organizations should provide staff training to ensure staff understands how to handle such requests.

Part C Organization Determinations, Appeals, and Grievances (ODAG)

When a Sponsor contracts with an external fulfillment vendor to mail checks, CMS stated the date the check left the mail vendor should be populated as the date paid. However, if a payment vendor is used for electronic payment, the date paid should be the date the electronic payment left the sponsoring organization. Claims and delegation oversight departments should understand how payment is made and ensure related universes are populated correctly.

As anticipated, in response to CMS’ final Part C and D rule that became effective January 1, 2019, because sponsoring organizations are no longer required to notify enrollees when their requests are forwarded to the Independent Review Entity (IRE), CMS specified that Sponsors can enter “NA” in the applicable ODAG and MMP SARAG fields.

Special Needs Plans – Model of Care (SNP-MOC)

There were several questions related to enrollee’s failure to complete the initial and annual Health Risk Assessments (HRAs) or to complete it timely. Specifically, CMS indicated the applicable fields in the Special Needs Plan Enrollee (SNPE) universe should be populated based on when the HRA was completed and returned by the enrollee. If you are not already doing so, make sure your case management teams are conducting outreach in accordance with your CMS-approved MOC and are able to demonstrate due diligence outreach detail, including an enrollee’s refusal and/or lack of cooperation, during an audit.  

Medicare-Medicaid Plan – Service Authorization Requests, Appeals, and Grievances (MMP – SARAG)

CMS responded to a variety of questions relating to the MMP SARAG field inclusions and the Medicare and Medicaid appeals processes. As examples, CMS indicated service authorization requests, claims, appeals, and grievances concerning Medicaid services should be included in the MMP – SARAG universes; all prescription drug requests except for those provided under Medicare Part B should be excluded; and universes related to the Medicare external appeal cases should only contain cases that involve Medicare services. CMS also offered new clarifications for MMP – SARAG inclusions/exclusions for applicable universes.

Medicare-Medicaid Plan – Care Coordination and Quality Improvement Program (MMP – CCQIPE)

In addition to ensuring they are following their three-way contract, MMPs should be documenting their various processes related to quality improvement effectiveness. CMS provides various examples of how sponsoring organizations can demonstrate quality improvement effectiveness, such as oversight reports used to track and/or report the quality improvement program evaluation metrics. CMS also clarified their expectations regarding the response for corrective actions plans for quality improvement activities, indicating sponsoring organizations should provide information on the initiatives they implemented to improve the measure’s performance when the measure goal was not met.  

GHG provides a host of services to help ensure program audit readiness, including universe review and validation and mock program audits. We also support clients with preparation and assistance during CMS program audits. GHG also acts as an independent validation auditor for Sponsors in need of IVA services. 


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Lisa Artale-Bross
Lisa Artale-Bross

Lisa Artale-Bross is a Senior Consultant at Gorman Health Group (GHG). In this role, she provides compliance assistance and guidance on regulatory requirements. Lisa brings GHG clients more than15 years of experience in state and federal regulatory compliance along with extensive audit and compliance expertise, passion, and dedication to her work.

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