The Centers for Medicare and Medicaid Services (CMS) last month released the agency’s 2018 Medicare Part C and Part D Program Audit Report. Such reports can be challenging to navigate through, but it’s important that health plans understand them in the event they experience an audit.
The Medicare Parts C and D Oversight and Enforcement Group (MOEG), a division of CMS, releases the report every year. It includes data from recent audits. The idea is to explain CMS initiatives and boost transparency of the entire auditing process. Program audits are conducted by MOEG to ensure Medicare Advantage and prescription drug plans are offering the right access to health care services and medications to enrolled seniors.
As CMS writes: “Regular and consistent auditing of these organizations…provides measurable benefits by:
• Ensuring enrollees have adequate access to health care services and medications; • Verifying sponsors’ adherence to selected aspects of their contract with CMS;
• Providing a forum to share audit results and trends; and
• Soliciting feedback from the sponsor community and external stakeholders on potential audit improvements.”
Changes to audit processes based on sponsor feedback. Among other things, CMS expanded technological capabilities and reduced the scope of data collection to make submissions more streamlined. It also extended the fieldwork phase from two weeks to three weeks, and made the audit validation and close-out process better.
Audit results. CMS reports lower overall audit scores between last year and the year before, from 1.10 in 2017 to 1.03 in 2018. Scores were lower in Part D Formulary and Benefit Administration (FA) and Part C Organization Determinations, Appeals and Grievances (ODAG). Average FA scores, though, showed improvement with a reduction of 62% in 2018.
Audit Enforcement. CMS imposed $396,736 in 10 CMPs. There were three intermediate sanctions against sponsors for non-compliance, but fewer CMPs imposed for 2018.
To view the full report, go here.
Medicare plans and pharmacy teams are increasingly subject to closer CMS monitoring and review, so an audit is more likely now than ever before. Typically, CMS audits plans once per audit cycle, which runs between three to five years. It’s important to be ready for an audit – especially if your health plan has performance issues. Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to ensure compliance and get you through the process.
Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve goals.
Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be scary. It’s necessary to get you the best rating possible. We will make sure your vendors are on board, too, supporting your efforts and all of the needs of the Star Ratings plan.
A four or five star rating is within your reach for 2020. We can help you get there.
About Tier 1
Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.
Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.
Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.
We’re here for you. Drop us a note at email@example.com and let’s get connected