Data Integrity and New Protocols for CMS Program Audits


Are you compliant for a CMS Program Audit of Medicare Advantage and Prescription Drug Plans? Mock audits can help with data integrity and new audit protocols.


By: Timothy H. Gundlach, Senior Manager, Change Healthcare Consulting

Over the past year, Change Healthcare Consulting services have seen several trends—and obstacles to avoid—that can help plans stay in compliance during a CMS program audit of Medicare Advantage and Prescription Drug Plans. Change Healthcare mock audits have recently shown that many plans struggle with data integrity issues or may get tripped up because some audit protocols changed after 2021.

Change Healthcare Consulting mock audits help plans ensure data integrity while testing overall operations and access to care.

The 2022 Centers for Medicare & Medicaid Services (CMS) Program Audit season is well underway, but it’s never too late for Medicare Advantage and Prescription Drug Plans to look at their Part C and Part D operational processes. Examining these processes, with the help of a healthcare consultant, also can help prepare for next year’s audits.

For plans that offer Medicare Advantage and Prescription Drug Plans, we’re seeing several trends—and obstacles to avoid—that might help plans stay in compliance this year or next before and during a CMS Program Audit.

Healthcare consulting and plans struggle with data integrity and audit-protocol changes.

While audits test many aspects of a plan’s operations, Change Healthcare Consulting services mock audits recently have shown that many plans struggle with data integrity issues or may get tripped up because some audit protocols changed after 2021.

CMS used to ask for data to be sent because of either standard or expedited requests. But because of audit-protocol changes first approved by the Office of Management and Budget in May 2021 and clarified in December, it’s possible that a plan may apply data that’s standard which should be expedited or vice versa.

Plans could be inadvertently omitting critical data. Some fields have been added to CMS universal-record formats, and some values that can be input have changed.

There also have been significant changes in CMS Program Audit columns. A value that used to be input in one column now may need to be placed in an entirely different one

Examples of record formats that don’t match up during a CMS Program Audit

The sample volume has changed to account for the consolidation of standard and expedited universe-record formats. If cases don’t match up during the audit process, your plan can appear to be out of compliance in the CMS audit.

You may have to remap where you place some data. And of course, when information is placed in the wrong area, it can be tagged as an Invalid Data Submission (IDS), leading to a poor audit result.

Here are some examples our healthcare consulting practice has encountered: We’ve seen dates and times of notification not matching. We’ve seen oral or written notification dates and times input when no notification was made. And sometimes we’ve seen oral notification date and time inputs that are prior to the decision date and time.

Mock audits test for data inconsistencies, input mistakes, and correct process requests.

A mock audit can help plans test for data inconsistencies and input mistakes. It also tests whether a plan correctly processes requests for services, appeals, or grievances in accordance with CMS requirements.

Most mock audits conducted by Change Healthcare take eight to 10 weeks, depending on the number of areas being audited. The process involves all operational areas within the plan that are responsible for processing Part C and Part D requests for organization, coverage determinations, appeals, and grievances.

Even when the current audit season winds down this summer, it’s good to test the operations of a plan to not only help ensure data integrity but also to see whether the plan is authorizing and providing appropriate access to care and to mitigate compliance risks by identifying gaps before regulators find them.

For more information on Change Healthcare mock audits, read our case study, Payer Shines in CMS Program Audit with Help From Government Health Plan Audit Services.

Learn more at Government Programs Consulting on the Change Healthcare website.

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