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Upcoming CMS Prior Auth Audits—Are You Ready?

by Julie Mason, President

As you are probably aware, CMS has announced that it will be conducting audits of the prior authorization processes for Medicare Advantage (MA) plans. The audits will evaluate whether MA plans comply with new coverage and utilization management requirements that went into effect January 1, 2024, in accordance with final rule CMS-4201-F.

CMS will be auditing via regular program audits as well as focused audits specifically targeted to the new requirements, including Compliance Program Effectiveness (CPE) to ensure that plans are conducting adequate oversight of the processes. The two types of audits combined will cover 88 percent of MA enrollees and are scheduled to begin in January. This means that the vast majority of MA plans be audited for the new requirements in 2024.

Due to the impact of Medicare beneficiaries’ access to care and the Congressional interest in MA plan compliance with the new requirements, these audits are among CMS’s highest priorities in 2024. CMS has invested heavily in resources to conduct these audits, including the use of physician reviewers for denied organization determinations (i.e., prior authorizations).

To ensure you are meeting these requirements and are adequately and appropriately documenting denied organization determinations, it is highly recommended that you conduct internal audits of processes involving the new requirements, and to do so as early as possible to allow time to correct deficient processes before receiving a CMS audit notice. CMS is taking these audits very seriously and we advise you to do the same.

How We Can Help

Mock Audits

Integritas Medicare and Toney Healthcare have partnered to offer a rigorous mock audit process to help MA and provider group clients evaluate their compliance with these new requirements. This partnership offers a unique value proposition for MA plans. The Integritas team, comprised of former CMS regulators and health plan operations and compliance executives, has decades of experience conducting mock CMS audits (both from within CMS and as consultants) and brings CMS insider insight to its mock audit services. Toney Healthcare, experts in health management, has extensive physician review expertise and deep knowledge of Medicare coverage criteria.

We can effectively evaluate your prior authorization processes with the new requirements, identify gaps, offer recommended corrective actions, and assist with implementation of process revisions.

Audit Support

Additionally, when you are notified by CMS of your 2024 audit (either program or focused audit), we can provide onsite or remote audit support to ensure your CMS audit goes as smoothly as possible.

Ready to learn more?

If you would like to discuss how Integritas/Toney Healthcare can assist with these activities, please contact us at 415.596.5277 or to discuss your needs, our capabilities and the audit process.


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