CMS Audits for 2020: Changes Amid COVID-19 Crisis

By Alexander Henrichs
Wed, Apr, 01, 2020

Over the last few days, CMS has released memos delaying or suspending some of their larger audit efforts while the country continues to work through the current public health emergency. The 3 areas hit so far are: Data Validation (DV), Risk Adjustment Data Validation (RADV), and Program Audits.

What We Know:

Data Validation: The 2020 Data Validation audit period was supposed to begin on April 1, 2020 but has been delayed until further notice. CMS notes that this delay is because the annual Data Validation auditor training is not ready. This training is compiled by CMS. Auditors cannot start their review work until they receive a passing score.

Risk Adjustment Data Validation: RADV activities related to payment year 2015 have been suspended until the public health emergency has ended. CMS expects Sponsors to suspend soliciting RADV related medical records from their providers but can submit any medical record documentation already obtained.

Program Audits: Are suspended until the public health emergency ends. CMS will continue their oversight of Sponsors in another manner, focusing on instances of noncompliance related to access to care which could result in member harm, and complaints alleging infection control concerns.

What We Don’t Know:

Data Validation: We don’t know how long this delay will last, and what exactly it entails. Though CMS mentions the training materials, the primary reason for the delay is likely due to COVID-19. CMS most likely wants plans to focus on member access and care. The Burchfield Group, An Aon Company has questions out to CMS regarding what type of activities can and can’t happen. For instance, the delay may only be related to conducting the DV interviews and walkthroughs, meaning data can still be provided starting 4/1/2020. Conversely, the delay could be for the entire DV process, prohibiting any transfer of data until otherwise informed.

Risk Adjustment Data Validation: We don’t know how long this suspension will go, and what commencement of the RADV audits will look like. Likely, the submission timelines will be extended to compensate for the postponement.

Program Audits: Like the others, we don’t know how long this suspension will last, and what happens to the 2020 Program Audits once the suspension is lifted. CMS has told us they expect to audit roughly 25 parent organizations each year. CMS may push the 2020 program audit calendar later, meaning the notice period will extend into August or September. CMS may work with a shortened the 2020 audit calendar and fit as many Sponsors as they can into it. Conversely, CMS may add unannounced 2020 audits into their 2021 plan.

What You Can Do:

Data Validation: Continue gathering your documentation as the audit is unlikely to be cancelled. This delay may provide an opportunity to do some additional internal review to make sure all process documents are up to date. Since the audit timeframe might be condensed this year, it’s important to have everything ready to ensure an efficient review.

Risk Adjustment Data Validation: Continue internal review of documentation already received for the 2015 payment year. Understand what is still needed, and plan on how to request the documentation from providers once the suspension is lifted.

Program Audits: Continue your readiness activities. If you had Mock Audits planned for this year, and are still logistically able engage in those reviews, do so. If you were expecting a program audit this year, and didn’t plan any Mock Audit activities, consider working in additional reviews to maintain your organizational readiness if able. There are external consultants in the industry with a high degree of flexibility who can help make Mock Audit activities happen in this temporary reality where everyone is working remotely.