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CMS Program Audits: Not for the Faint of Heart


CMS program audits aren't for the faint of heart; they are stressful, time-consuming, labor-intensive, and can impact the future of your Medicare Advantage or Part D plan. If a health plan waits for a CMS audit notification to start preparing, a bad outcome is virtually guaranteed. For example, if a health plan only compiles audit universes at the time of a CMS audit, there is no time to identify problems (either in the universe itself or in operations as identified by the data in the universe), and thus no time to correct such issues. does


Note that CMS (Centers for Medicare and Medicaid Services) isn't looking for perfection. They conduct these audits to determine whether the plan is routinely reviewing operations and correcting identified deficiencies timely so that enrollees receive appropriate care. CMS requirements exist to ensure the quality of care and appropriate coverage for Medicare enrollees.


With that in mind, Medicare health plans should address the following questions before receiving a CMS program audit notice:


• Have you conducted an annual risk assessment?

• Do you conduct regular monitoring activities and audits of both internal and delegated activities subject to CMS requirements?

• Have you identified compliance issues and started (or completed) corrective actions to remediate them?

• Have you reviewed your plan policies to ensure the process(es) meet current CMS requirements?

• Have you conducted annual FWA (Fraud, Waste, and Abuse) and Code of Conduct training?

• Do you get regular updates from your FDRs and review them to ensure they adhere to CMS requirements?


These are just a sampling of the self-evaluation questions you should be addressed on a continual basis to ensure you are audit-ready all the time. Due to the complexity of the Medicare Advantage program and limited internal resources, many Medicare Advantage and Prescription Drug Plans engage external resources to help them stay on top of operational, compliance, and audit readiness activities.


CMS program audit assistance services


INTEGRITAS MEDICARE is a team of experts with deep experience in the Medicare Advantage and Part D programs, committed to providing you with accurate guidance for increasing outcomes in CMS program audits and various other types of audits to help drive the organization towards improvements in these programs. Regardless of the size of your Medicare Advantage (MA) membership or the number of years in the MA and Part D space, INTEGRITAS MEDICARE delivers customized solutions to fit your compliance requirements with our professional CMS program audit assistance services.

Ready to talk?


If you are ready to talk, we are ready to listen. CMS program audits are one of the many areas with which we assist clients, and our experts execute them with strict confidentiality. We act in accordance with CMS guidelines to offer you the following invaluable benefits:


• Avoid costly mistakes in the audit process

• Identify risks before a CMS program audit

• Receive assistance in correcting identified deficiencies

• Learn what to expect from a CMS program audit


Get in touch with us today for the necessary assistance!


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