Breaking: 2019 Program Audit Protocol

Let’s get right into it. Last night, the Centers for Medicare & Medicaid Services (CMS) provided detailed information regarding changes to the 2019 Program Audit process. Here, I break down the memo and briefly explain impact.

  • CMS incorporated validation audit updates to the Program Audit Validation-Close Out document. No surprises here as this information was previously communicated in the Call letter of the 2019 Final Announcement.
  • Audit notices are scheduled to be sent between the months of March and July, 2019. This window is two months shorter than the 2018 window, which ended in September. While teams can plan accordingly based on this information, CMS may issue an ad hoc or unplanned audit notice based on a tip, allegation, or newly identified risk. Do not let July pass by and start breathing a sigh of relief. Talk to your Compliance Officers: CMS account managers continually request information regarding plan performance and significant issues. These matters may be referred to the Central Office for further action.
  • The agency is suspending the collection of Supplemental Questionnaires for Coverage Determinations, Appeals, and Grievances (CDAG), Part C Organization Determinations, Appeals, and Grievances (ODAG), and Medicare-Medicaid Plan (MMP) Service Authorization Requests, Appeals, and Grievances (SARAG). They note the info is relevant when conducting root cause or pulling together impact analyses, so best bet is to still have them ready.
  • Arguably the most significant change, modifications are being made to the methodology to review misclassification of beneficiary calls, including the suspension of collecting the Call Log tables. Instead, CMS will review a sponsor’s oversight of the call routing process during its review of Compliance Program Effectiveness (CPE). In my recent experience, the collection of call log data as well as the classification of calls continued to frustrate sponsors. However, the targeting of call log samples was one of the most eye-opening and direct avenues to identify misclassification. It also shed light on opportunities to improve customer service overall, especially when it came to listening to calls handled by a vendor. Shifting from targeted samples to a review of process appears to be a step backwards. Since processes vary sponsor to sponsor, listening to targeted calls was a consistent method to uniformly measure a sponsor’s compliance.
  • Speaking of CPE, CMS will suspend some data collection including the Self-Assessment Questionnaire and some universe data points in the review of the compliance program. The agency realized some of this information was either covered in tracer samples, not pertinent to identifying increased risk of non-compliance or no longer required. It is not expected this will significantly reduce sponsor burden, however it does demonstrate the agency is continually evaluating methodology to make it more meaningful.
  • Additional program audit elements suspended to reduce overlap include the Website Review, previously conducted in Formulary Administration, and Enrollment Verification in Special Needs Plan – Model of Care.
  • Part D, take note: CMS will be evaluating the implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016 through the program audit process. How so? CARA allows sponsors to limit “at risk beneficiary” access to coverage for frequently abused drugs via drug management (DM) programs starting next year. The agency is clarifying that these decisions made under DM programs are not defined as coverage determinations, and therefore will not be collected in data universes. However, at-risk redeterminations (appeals) will be collected as part of the appeals tables 6 and 8 (Standard and Expedited Redeterminations, respectively).
  • Timing is everything, and sponsors should welcome the anticipation of the February, 2019 release of the final appeals guidance. While CMS acknowledges they do not anticipate significant changes from the draft to the final, they note they will provide opportunity to the industry to implement the updates before auditing these changes to compliance standards. Once the final guidance is released, CMS notes they will communicate how and when any audit standards will be affected. Keep in mind, audit review periods are retrospective. Ideally, CMS would provide a future effective date for the appeals guidance so that sponsors can fully evaluate and implement changes. This is done in the annual enrollment guidance as well as for many provisions in the Marketing Guidelines, so why not for key appeals guidance? Time will tell.

We still wait for the 2020 Program Audit Protocol 30-day notice for public comment to be released. All in all, reduction of burden on sponsors and focus on patient care seem to be a factors in implementing these changes.

What to do next: Sponsors should evaluate what changes need to be made to current audit preparation processes. While some items are easily implemented (such as the suspension of data collection), questions remain. Will CMS be reviewing the call routing process desktop procedures only, or will they solicit training tools and other procedures? Will vendor call routing processes be collected and reviewed, or will vendors be required to explain their processes during CPE week? Will the appeals chapter really be released in February? Contact me to schedule a call to discuss what these changes mean for your own audit planning and general oversight. I’ll be caffeinated and ready!