CMS Seeks Comments to Proposed Audit Protocol Changes

In a Health Plan Management System (HPMS) memo dated August 20, 2019, the Centers for Medicare and Medicaid Services (CMS) announced they are seeking comments to their proposed changes to the current program audit protocols, which expire in 2020.  All protocol areas have updates and clarifying language to the Audit Process and Data Request documents. 

Noteworthy changes include:

Compliance Program Effectiveness (CPE)

  • Removal of the CPE Self-Assessment Questionnaire

Coverage Determinations, Appeals and Grievances (CDAG)

  • Removal of the CDAG Supplemental Questionnaire
  • Removal of Tables 9, 10 and 16
  • Reduced the data integrity sample size to 65 (from 75)
  • Increased the Grievance sample size from 10 to 20
  • CMS is excluding cases that require an Appointment of Representative (AOR), where no AOR has been received, in Tables 1-8, 14 and 15

Formulary Administration (FA)

  • Removal of the ‘Website’ section of the Audit Process and Data Request
  • Increased the Transition sample size from 15 to 30, clarifying claim selection will include both protected and non-protected class drugs

Organization Determinations, Appeals and Grievances (ODAG)

  • Removal of the ODAG Supplemental Questionnaire
  • Removal of Table 14
  • Removal of ‘Dismissals’ from the data integrity sampling to reduce the sample size to 60 (from 65)
  • Removal of OD approved cases from the Clinical Decision Making section, reducing the sample size to 35 (from 40)
  • Increased the Grievance sample size from 10 to 20
  • CMS is excluding cases that require an AOR, where no AOR has been received, in Tables 1-2, 4-6 and 11-12

Special Needs Plan Model of Care (SNP MOC)

  • Removal of ‘Enrollment Verification’ audit element

Additionally, CMS has removed the Medication Therapy Management (MTM) audit area from the protocols.  Impact Analysis templates for all audit areas remain unchanged.  The updated protocols, including a crosswalk of changes, can be found here.  Comments are due to CMS no later than October 15, 2019.

The trend in reducing burden to Plans continues with these proposed changes.  Gorman Health Group (GHG) suggests internal discussions related to the proposed changes start now so Plans are best prepared when the finalized protocols are distributed.


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Tina Bailey
Tina Bailey

Tina Bailey is Vice President of Compliance Solutions at Gorman Health Group (GHG). In this role, she assists health plans in preparing for and undergoing Centers for Medicare & Medicaid Services (CMS) audits, directs onsite and remote focused audits, assesses new and existing plan readiness, produces Part C and Part D delegation oversight programs, leads large-scale member/marketing material review, assists with CMS/state applications, and creates and conducts focused trainings.

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