The 2019 Program Audit Protocol

On Tuesday, December 4, 2018, the Centers for Medicare & Medicaid Services (CMS) released a Health Plan Management System (HPMS) memo addressing updates for the 2019 Program Audit Process. The biggest surprise? Many of the protocol changes are intended to reduce the burden on organizations via a reduction in audit deliverables, most notably the suspension of collection of supplemental questionnaires and the Call Log universes. But while sponsors will be happy with the deliverable reduction, the flip side of the coin is CMS has put Pharmacy teams on notice that in 2019, it will begin evaluating sponsor’s implementation of the Comprehensive Addiction and Recovery Act in sponsor’s drug management programs. CMS also teased the finalization of the much anticipated integrated Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) chapters, but mostly just to say that additional information is forthcoming. Finally, CMS let sponsors know to keep an eye on their in boxes as audit notification letters will be issued between March and July of 2019.

A Reduction in Burden

While CMS is suspending the requirement to submit the Call Log universes in CDAG and ODAG, it is no cause to celebrate. CMS has stated it will be taking a broader look into call misclassification and will be looking to the Compliance Program Effectiveness (CPE) portion of the audit to review sponsor’s oversight of call routing processes. Compliance Departments, beware – it is time to consider adding these monitoring and auditing activities to the 2019 work plans you are currently developing.

CMS suspended the collection of the CDAG, ODAG, and Service Authorization Requests, Appeals, and Grievances (SARAG) Supplemental Questionnaires as well as the CPE Self-Assessment Questionnaire. CMS acknowledged that while this information is important, it is usually addressed during the webinars, and the questionnaires are often more relevant as reference materials when sponsors are producing root cause and impact analyses.

While CMS is still utilizing the universe record layouts issued in 2017, CMS has stated it will make three CPE universe data fields optional. This was done because CMS does not feel these fields can be clearly tied to an increased risk of non-compliance. The optional fields are CPE FTEAM Colum C, “FTE Contract Effective Date”, and CPE ECT Columns I and J, “Medicare Compliance Department Employee?” and “Compliance Department Job Description.” You may continue to populate these fields if your systems are already programmed for them, but they will not generate an Invalid Data Submission if left blank.

The Special Needs Plan Model of Care (SNP MOC) and Formulary and Benefit Administration (FA) areas got some love, too. CMS is suspending the evaluation of the FA website review and the SNP-MOC Enrollment Verification elements.

New for 2019: Implementation of the Comprehensive Addition and Recovery Act of 2016 (CARA)

In 2019, CMS will begin evaluating sponsor’s implementation of CARA. CARA is a targeted program to limit at-risk beneficiaries’ access to coverage of frequently abused drugs via sponsor’s drug management programs. While beneficiary at-risk determinations are not defined as initial coverage determinations, they are expected to be reported as part of the total redetermination count within the standard and expedited redetermination universes.

Protocol Changes Expected in Response to Integrated Chapters 13 and 18?

CMS has let sponsors know they have heard the industry feedback on the proposed guidance but does not anticipate significant changes to the final chapters. We can expect the final version in February 2019, and CMS is allowing time for sponsors to implement the updates before including the changes in the audit protocols. However, CMS advised more information on compliance standards is forthcoming once the final guidance is released.

If you would like more information or assistance regarding the 2019 Program Audit Protocol updates, Gorman Health Group is happy to help. Contact us at directly here.




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Melissa Bailey
Melissa Bailey

Melissa Bailey is a Senior Consultant at Gorman Health Group (GHG). In this role, she offers our clients assistance and leadership in executing compliance activities while providing insight on regulatory requirements and industry best practices. Melissa brings GHG more than 15 years of healthcare experience.

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