New CMS Audit Protocols Increase Documentation Requirements for Medicare Plan Sponsors

By Derek Frye & Yvonne Zachman Fiedler
Wed, Mar, 01, 2017

 Medicare health plan sponsors that are scheduled for an upcoming CMS audit may be in for some unpleasant surprises. That’s because Medicare is raising the bar in terms of the level of documentation expected for Medicare health plan sponsors in 2017 (per CMS’ updated audit protocols), especially when handling beneficiary grievances and appeals.

Medicare plans are generally audited by CMS once every 3 to 5 years. CMS issues a report in November of each year noting areas in which plans were generally found to be deficient during the previous year’s audits. CMS also revises and publishes audit protocols each year so plan sponsors will know what to expect as part of the audit. Medicare Advantage organizations are then notified by the agency that they will be audited in the coming year.

A cross reference of the agency’s 2017 audit protocols against the 2016 audit protocols shows that CMS auditors will be looking more closely at health plan call log records when determining how well plans are handling beneficiary grievance and complaints. This scrutiny will apply to incoming beneficiary calls concerning both Medicare Part C and the Medicare Part D drug benefit.

Here’s an example of how this may play out: Suppose a Medicare beneficiary calls in to the plan to complain that a doctor who was supposed to be in the plan’s network refused to see this beneficiary when she tried to get an appointment. Under CMS regulations, a health plan has 30 days to conduct a thorough investigation of the beneficiary’s complaint and respond to the member.

Under the new protocols, CMS will be requiring formal documentation on how the problem was resolved at the beginning of the audit.  The submission of a universe containing call transcripts and notes at the beginning of the audit formalizes the process and allows the auditor to verify that the call was handled appropriately and sufficiently documented. In addition, the auditor may inquire if the plan contacted the provider in question to find out why the patient was not accepted. The auditor will seek verification that the customer service representative clearly explained to the beneficiary how the issue would be resolved. The auditor may also choose to examine the current provider directory to ensure it has been appropriately updated.

In other words, your plan may need to document and demonstrate that your internal people did a little bit more work on behalf of the beneficiary to correct the problem. Keep in mind that what constitutes a thorough investigation and an adequate response to the member is still subject to the CMS auditor’s discretion and interpretation.

Here are some things to keep in mind to help you stay ahead of changing CMS audit requirements:

· Make sure your internal processes and systems capture member call transcriptions. If your plan will be audited this year, and you won’t be able to capture transcriptions prior to being audited, be prepared to let the auditors know when you plan to implement this capability.

· Don’t go it alone. It’s more important than ever to get out and hear from your colleagues, Medicare plan peers, and others outside your organization. Go to industry conferences and network to investigate, hear and learn from other plans grappling with the same audit-related issues. Or work with an outside CMS compliance consultant who is familiar with these changes.

· Be prepared for inconsistencies between CMS auditors. It is not possible for plan sponsors to know ahead of their scheduled audit which specific CMS auditor will review their organization. Regional auditors travel, so it’s a roll of the dice in terms of who will do your audit. And even though the agency tries to apply consistency, individual auditors differ in how they assess and interpret findings.

· Conduct an independent, third-party mock review of your organization – months to a year before your scheduled audit date. Preparation is key, and knowing where there are gaps or deficiencies within your organization ahead of time will allow you to address these before the CMS auditors do.

If your plan is up for audit soon, keep in mind that the documentation requirements may have changed significantly since you last went through the process. It’s important to plan ahead. Pay particular attention to how your incoming beneficiary calls are recorded, transcribed, entered into your systems, and resolved. Getting an independent third-party mock review of your organization can also help you be better prepared for your next audit.