CMS Scales Back 2020 Program Audit Changes

With current program audit protocols set to expire on April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) have decided to scale back the sweeping proposed changes published in 2018, as reflected in their recent notice posted on August 16.

According to CMS’ supporting statement, over 700 comments were received by the agency in response to the proposed changes, which covered not only program audit protocol but also timeliness monitoring data requests. It was acknowledged most commenters supported the goal to simplify data collection for audits, but many were concerned about the time needed to reprogram systems to accommodate the changes.

CMS has had the authority to extend the current documents, which is how the agency is proceeding, with some minor updates. The package including supporting statement may be reviewed here.

Updates: Timeliness Test tables in Coverage Determinations, Appeals and Grievances (CDAG) and Organization Determinations, Appeals and Grievances (ODAG) regulatory references; increase of grievance samples from 10 to 20; edits to Compliance Program Effectiveness (CPE) questionnaires, and various table edits affecting each program audit data request tool.

Removed: Medication Therapy Management (MTM) materials (protocol suspended); CPE self-assessment questionnaire; CDAG questionnaire; ODAG questionnaire (reducing duplication and burden); CDAG Tables 9, 10, and 16, addressing Standard IRE Auto-forwarded Coverage Determinations and Redeterminations, Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations, and Part D Call Logs, respectively; ODAG Table 14, Part C Call Logs; Website Review of Formulary Administration protocol; Enrollment Verification of the Special Needs Plan Model of Care protocol.

For the organizations responsible for supporting Medicare Advantage and Part D functions subject to program audits, the scaling back of revisions should be a welcome change, as it reduces the amount of re-programming to be done. One of the most impactful initial proposals was to consolidate certain CDAG and ODAG universes. On the other hand, while CMS had proposed to eliminate the impact analysis (IA) excel documents and instead leverage universe record layouts for requesting data, the IA documents remain.

CMS’ next step is to publish a new data collection request under a separate Office of Management and Budget (OMB) control number. Expect this request to reflect recent regulatory changes (think of the new appeals chapter), the simplification of tools, and to allow for more time to implement system changes.

Comments from the public are due October 15, 2019.