CMS Audit Guide for 2020: What to Know

By Alexander Henrichs
Wed, Feb, 12, 2020

As we enter 2020, now is a great time to review CMS’ recent changes and begin preparing for audits. The first thing to know is that CMS will not be implementing its new audit protocol to the extent previously expected. The agency announced in August 2019 that it would extend its original 2016 collection request requirements, with minor revisions, until 2021. However, there are still some important changes to be aware of that this CMS audit guide will walk you through.

Preparing for CMS Program Audits in 2020

Is your plan expecting to get selected for a CMS Program Audit this year? We’re in year two of the current 4-year cycle, and if this cycle follows the strategy of the previous cycle, we’re expecting mid to large-size plans to be selected. If you are expecting an audit this year, we recommend assembling your resources now and constructing your team.

If you aren’t expecting a CMS Program Audit, continue planning, evaluating, and practicing. For example, what is your audit strategy? Do you have an audit checklist? If so, what is its status? Read more about detailed preparation steps for a Program Audit here.

Luckily, there are only minor protocol changes for the 2020 Program Audit year. While some impending changes to protocols came to light in August, few actual changes occurred during the 30-day comment period in December. Once again, CMS will use the bones of the current protocols, with sweeping changes coming in time for the 2021 program audit year. With 2021 protocols still being drafted, it’s best to prepare using current protocols. For more information about what’s coming in 2021, read more here.

TMP Audits

Data for TMP (Timeliness Monitoring Project) audits is likely due soon. This is the last year that Part D will be included in TMP audits. In the future, this will make it significantly easier to provide documentation for the yearly audit.

For a successful TMP audit, it’s important to know your risks, which means evaluating your data in the following ways:

  • Conduct your own evaluation of data integrity, ensuring that your data is complete
  • Perform minor testing walkthroughs with business operational areas
  • Complete timeliness calculations.

If your organization has changed your claims or authorizations system in the past year or experienced high staff turnover and is facing resourcing issues, you may benefit from outsourcing these evaluations. A vendor can verify the integrity of the universes and provide timeliness results by applying a proprietary tool to validate fields.

1/3 Financial Audits

If you weren’t selected for CY2018 review in 2020, and weren’t selected last year, prepare for a CY2019 notice this fall and being audited in 2021. Preparing for this audit is time-consuming and detailed, with many documents and requirements to finalize prior to the actual audit. Being as prepared as possible ahead of time will alleviate some of the burden when the audit happens and help set you up for success.

Data Validation Audits

The 2020 Data Validation Audits (DVA), reviewed CY2019, has numerous changes from the DVA process last year. Make sure your organization is well prepared.

Evaluate your resources, including levels of competency and experience. If you’ve had changes within the organization, you need to evaluate your team’s readiness. For a successful audit, it’s critical that business units work together, despite the many complexities and multiple layers they may face.

There are two approaches to the Data Validation Audit:

  • For the first approach, we recommend using an internal seasoned project manager or CMS expert to help prepare your plan for the audit. Your team will need to understand how to interpret complicated guidance and post the correct counts by the CMS mandated deadlines. You may need to work with your auditor to clarify the census file format, documentation requirements, and audit schedule.
  • For the second approach, plans can also use an external resource, working as an extension of the team. This resource can provide data validation consulting by completing a pre-assessment and preparing your plan for the data validation audit. The external resource should help interpret unclear guidance and should be able to assist your plan in meeting all reporting requirements.

Recovery Audit Contractor Audits

The frequency of Recovery Audit Contractor (RAC) audits have slowed recently due to CMS changes relating to RAC contractors. These audits are known for their high administrative burden, resulting in a lot of recovery. Still, CMS has not decided to eliminate these audits and reserves the right to increase RAC audits at any time. Therefore, it is best to continue to prepare for these audits.

Using the CMS Audit Guide to Prepare for Audits in 2020

While there are fewer changes in CMS audits coming this year, there are still some important considerations to be aware of. As you prepare your organization for successful audits, the most important things you can do are stay up-to-date with CMS changes and have your audit resources as prepared as possible.

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