Preparing Your Health Plan for 2020: A CMS Program Audit Checklist

By Alexander Henrichs
Mon, Jan, 13, 2020

Is your health plan ready for its next CMS program audit? With CMS’s continually changing requirements, a readiness checklist can play an integral role in improving your audit performance. Prepare for success throughout the audit lifecycle with these CMS audit insights and best practices for each phase of the process. While a checklist is not a substitute for understanding all of the myriad regulations and manuals applicable to plans, a CMS audit checklist can help guide you through the audit cycle.

CMS Program Audit Checklist Stage 1: Before the CMS Audit Notice Arrives

Given the constantly changing Medicare rules and requirements, it is essential to start preparing for a CMS audit as early as possible— ideally before receiving the audit notice.

Here are 3 key steps to take before receiving the audit notice:

1. Prepare the Program

Determine which types of monitoring and oversight are currently in place, the recent results of those activities, and where any opportunities or risks may be. Have an internal discussion about resources and budget. Is there internal capacity for additional oversight? If you’re planning on using outside resources, such as a consultant, be sure to budget appropriately.

2. Evaluate the Personnel

Evaluate personnel to create a dedicated audit oversight group, or, if such a group already exists, consider the tenure of your team—who has experience with program audits, with past health plans, and/or with current health plans?

3. Consult a Professional

Schedule a conversation with an experienced program audit consultant to help you determine your audit readiness and how to better prepare. They can assist with preparing for a program audit, support your organization while a program audit is being conducted, and work with your organization behind the scenes during a validation audit.

Pro tip: Create an execution plan for the audit. This plan should include a key point of contact for every business involved, a list of personnel involved—such as the system driver, the note-taker, and the researcher for each audit module—and timelines.

CMS Program Audit Checklist Stage 2: After Receiving the CMS Audit Notice

Hopefully, you’ve already prepared for the eventuality of a program audit. Now, you’ve received your notice and the clock is running. You have only 15 business days to get CMS your universes.

Check all the boxes in this stage of the CMS program audit checklist and you’ll be much better prepared for the webinar.

Here are 2 key steps to take after receiving the audit notice:

1. Gather the Data and Personnel

The data you present must be perfect, so invest time in ensuring its quality. If you don’t have a dedicated audit oversight group, designate key personnel to respond to the audit. The clock starts on providing the data universes the day you receive the program audit notice, so informing key personnel throughout the operational areas, including FDRs that will be providing data for the universes, needs to happen quickly. Reviewing the universes after the data has been provided by the operational areas and FDRs is also vital. An experienced program audit consultant can be beneficial in this area. Universes should be reviewed for completeness, against the current protocol requirements, and evaluated for immediate risk.

2. Practice the Delivery

There is no substitute for practice, and practice reviews are the best way to prepare. Conduct practice reviews via a webinar platform to mimic the CMS webinar environment. Try to turn around requests within the short timeframes CMS uses in the audit. Be sure to involve clinicians, for example, a pharmacist for pharmacy, a physician for medical, etc. It’s essential that these clinicians have little or no operational role within the plan, just like CMS. Your practice auditor should have experience with other health plans and experience with recent CMS findings. An experienced program audit consultant can be valuable here, as well. They will know the types of requests CMS will target, the cadence and flow of the webinar reviews, and can assist with a plan when risks are identified. Practice is best conducted in the time after universes have been submitted and before live reviews begin with CMS personnel.

Pro tip: To help ensure that your CMS audit goes smoothly, have backup personnel prepared and on-call to perform as the system driver, the note-taker, and the researcher for each audit module.

CMS Program Audit Checklist Stage 3: During the Live Webinar

The webinar is the most important thing your entire organization will do that day. Audits are difficult. Make sure you have buy-in throughout the organization, from the executive suite down, to have the support you need for success.

Here are 2 key steps to take during the audit:

1. Review Samples

The samples for most elements will be received 1 hour prior to the review webinar commencing. During this hour, devote resources to reviewing each sample as thoroughly as possible to identify any risks. If risks are identified in specific samples, think of a way to manage the discussion during the review with CMS in attempts to avoid the issue. If your organization has the resources, continue researching the samples while the webinar takes place. The deeper you can understand a sample before CMS gets to it, the more you’ll be prepared for what type of questions CMS might ask.

2. Presenting to CMS

This can be the most stressful part of the program audit for many involved. CMS will have dedicated auditors that will review samples from most elements (FA, CDAG, ODAG, SNP-MOC) concurrently. It’s critical to have a dedicated speaker from the plan. Each element should have a separate presenter or ‘driver’ dedicated to that area. CMS currently utilizes WebEx for these webinars, and the driver should familiarize themselves with the functionality – most importantly, the screen pause feature. The driver should sign out of all communication applications (email, IM, etc.). If an FDR is involved with the review, and they are off-site, have a ‘back door’ communication method set up in the event that you need to have conversations without CMS listening in. For this portion of the audit, having an experienced program audit consultant could be vital. Things can get tense and borderline chaotic in these rooms from a plan’s perspective. A consultant can guide the speakers and presenters around any uncomfortable issues or pre-identified problems, control the mute button, and provide a calming presence for all involved.

3. Manage the Audit Carefully

Support personnel, such as researchers and note-takers, need to have defined roles and responsibilities. Make sure you manage your timeline – you need to respond to all the samples from CMS during the webinar, or you will have to submit your responses to the samples for review.

Pro tip: Don’t voluntarily disclose additional information and, when in doubt, mute the phone and discuss things with the other participants. Whatever you do, do not argue with the auditors during the webinar. There will be avenues for you to voice your disagreements, but a confrontation at this point is ill-advised.

CMS Program Audit Success

Every audit will be different, and CMS requirements are constantly changing. The most successful program audits either have experienced consultants or a very engaged and robust oversight department that has conducted extensive monitoring, mock audits, and practice walk-throughs throughout the entire audit cycle. Preparation is invaluable.