Last Call: CMS Program Audit Protocol 30 Day Comment

Since this is one of the most restful times for compliance professionals (insert sarcasm face here), you may all have plenty of time to review the most recent release of the Centers for Medicare & Medicaid Services (CMS) program audit protocol package. On Friday, CMS released a memo announcing the opportunity for the industry to provide comment.


  • Audit letters are to be sent between March and July 2020. There are 25 parent organizations set to undergo routine audit in 2020.
  • In response to the August release, the agency received 109 unique comments and adopted many suggestions, such as removing columns no longer needed.
  • Guidance on the process for reviewing the Employee and Compliance Team and first tier entity samples was provided in the CPE audit process and data request document. This methodology has continued to evolve over the years, and certainly the industry should be pleased with this clarification.
  • Every audit area has been updated with refined data requests and/or revised instructions. CDAG and ODAG specifically have been updated to align with the Part C and D Enrollee Grievances, Organization/Coverage Determination, and Appeals guidance. For example, edits were made to accommodate revised notification requirements and exclusion of withdrawn cases.
  • CMS is accelerating the timing of scheduling of universe integrity testing. The worst-case scenario mailing policy has also been removed from their guidance.
  • The agency also removed reference to Tracer Case Summary Evaluations during Phase II, Audit Field Work, although reference to the onsite review remains. They did not provide clarification in the data request as to whether sponsor has a choice to provide only the tracers or also the supporting documentation ahead of time.
  • Additional detail is provided relating to an audit’s impact on Past Performance Reviews. This clarification should be evaluated for those organizations considering new applications or expansions.

There are also a number of requests and comments not addressed. For example, one sponsor requested CMS provide Excel versions of the universe tables. Another sponsor suggested changing a dismissal column to a streamlined, numerical field to indicate type of request dismissed (such as 1 for grievance, 2 for pre-service organization determination, and so on).

Make sure you send this revised draft package to your key business partners who typically participate in the audit process, including anyone involved in data preparation in the organization and at your delegates. Now is the time to request additional clarification or changes.  Feedback is due on January 27. Happy reading!


Stop, Just Stop: A Prevention Control

I do not know one compliance professional who considers this time of year a restful one. There are budget meetings, audits, new product launches, and readiness activities filling their bag of worries, when so many others are counting down the hours to taking the week off. Even if these folks are taking vacation time, the ones I know will succumb to the bad habit of checking email while at family luncheons or while shopping the post-holiday sales.

While conducting an audit recently using the Centers for Medicare & Medicaid Services (CMS) program audit methodology, it dawned on me that leadership does not get a sense of what a plan gets right in an audit report, outside of the rare best practice identified. Many requirements roll up to the three Compliance Program Effectiveness elements of Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities. It can be disheartening to just receive the bad news, but it’s the way it is.

There will always be something that needs improvement or refinement. As we close 2019, take a moment to do the following:

  • Reflect on the controls you have in place that are working well. If you have not taken stock in what those are, take the opportunity to do so.
  • Express gratitude to the people around you in compliance and operations who collaborate and partner with you even during the most trying situations, whether it’s launching a new product or on-boarding a vendor who does not know what protected health information is.
  • Apply the compliance controls to your life. Take a day off, including from your email. This prevention control is an important one to avoid burnout and stress-related health issues.

There is so much to be excited about in 2020. Be well for it, and I will see you then!

CMS Fall Conference: Looking Ahead to 2020

The Centers for Medicare & Medicaid Services held their Medicare Advantage and Prescription Drug Plan Fall Conference & Webcast yesterday in the pleasantly comfortable city of Baltimore, MD. Collaboration and transparency seemed to be themes in the various sessions, covering topics such as the enhancement of Independent Review Entity data reporting, integration policies for 2021 Dual Eligible Special Needs Plans, and one-third financial audits. Currently, all session information is in the Upcoming/Current Events section of CMS’ website but it is anticipated it will move to Event Archives, along with video recordings of each session to follow in the future.

A blended panel of CMS and health plan representatives provided advice and specific practices on accessible communications. The speakers were well-prepared and provided many suggestions and examples during their allotted time, such as: interpreters via video, centralized database for member communications preferences, listening to live calls to ensure call center representatives are capturing communication requests, quarterly regression testing on websites, and hosting an inclusion and diversity week. One panelist effectively summed up the spirit of the session suggesting not to only think about the requirement, but to put the consumer first.

While not explicitly stated, accessible communications practices can and should be leveraged by sponsor partners such as delegates, providers, and community agencies participating in the MA-PD program. As I mentioned in a previous post, CMS released best practices regarding communications accessibility. No, these requirements may not be in the ever-present program audit protocol, but this is just as important of a focus area. If a member is not able to interact with their plan, how can they effectively access their benefits and services? My advice: assign one of your most creative employees to think of innovative ways to ensure equal access regardless of abilities.

The keynote delivered by Demetrios Kouzoukas, Principal Deputy Administrator and Director of the Center for Medicare, included glowing statistics regarding the state of Medicare Advantage and Part D. He acknowledged even with the many improvements completed (such as broadening benefits, streamlining the materials process, and implementing new legislation), the agency is not resting on laurels. He said the administration will continue to protect the program and build on elements that work well. Based on the messaging, this next year looks to be a continuation of collaboration and transparency for CMS.

2021 CMS Application Season: 133 Days

Now that October first is behind us, and everyone has had time to evaluate all the new benefits being offered for 2020 (Just kidding – reviewing what’s out there is an enormous task!), it is time to think about the 2021 plan year.  There is no rest in the field of Medicare Advantage and Part D.

Some folks have already started with their 2021 application and expansion planning. Network providers might be in negotiations, state licensure filings are being drafted, and perhaps organizations are conducting feasibility studies to determine how to put their best foot forward in this market.

Other organizations might be taking a more cautious approach, and perhaps may not have gotten the head start that others have. If this sounds familiar, don’t worry, this is pretty common, but it’s time to make some decisions.

CMS has released the draft applications for both Medicare Advantage and Part D for industry comment. There were no major changes, but drafts are always worth a look as this is your opportunity to give the agency valuable feedback.

If you have not submitted a new application or a service area expansion request in a while, it is important to understand how the process has evolved. Document requests have changed, time frames may be different, and the CMS review process can be a challenge if you do not know what to expect. If you have never submitted an application, be assured that the agency releases templates, instructions, and training. However, not everything is straightforward, and I say this having worked with many experienced plans who on an annual basis still struggle to understand the requirements or the review process.

Review the applications and if you have questions about the process or the requirements, start working them out now. You have 133 days until applications are due on February 12.

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.