The Centers for Medicare and Medicaid Services (CMS) announced in a recent memo that officials are seeking comments to their proposed audit program protocol changes. This blog will outline some of the most important changes and a reminder of steps health plans can take if they receive a CMS audit notification.
Key Proposed Changes Through 2020
- Formulary Administration “‘Website” section removal of the Audit Process and Data Request
- Transition sample size from 15 to 30
- Removal of the CPE Self-Assessment Questionnaire and the ODAG Supplemental Questionnaire
- Removal of ‘Dismissals’ from the data integrity sampling
- Removal of OD approved cases from the Clinical Decision Making section
- Increased the Grievance sample size
- Removal of ‘Enrollment Verification’ audit element for SNP MOC
- Removal of the Medication Therapy Management audit area
For the full list and a closer look at all of the proposed changes to audit protocols, check out the memo here. CMS is accepting comments through Oct. 15.
Many of the changes would reduce the burden on health plans. Even so, health plans should review any and all changes. The chance of a plan getting a program audit has increased and continues to grow. CMS is now reaching out to nearly 100% of plans every four via plan audits. Audit notice letters are typically sent March through July.
Plans should take steps sooner rather than later to address the changes and anticipate an audit in the future. The best way to deal with a CMS audit is to be prepared.
We can help.
The team at 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, create corrective action plans and more. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions and help you through the process from start to finish.
Tier 1 CEO Brent Hiley has been both the lead for CDAG (coverage determinations, appeals and grievances), the lead for FA (formulary administration) and even overall audit director, ensuring coordination of all elements related to data requests, deliverables, impact analysis and root cause summaries. He can provide onsite audit support for teams to ensure they are prepared for various questions that might be asked and coach them on how to approach certain aspects of the audit.
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.
CEO Brent Hiley 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.
Drop us a note at info@tieronepc.com. We’re here to guide your health plan every step of the way.
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You’re a smart cookie.
If you were a scented candle they’d have to call it Perfectly Imperfect (and it would smell like summer).
You’re gorgeous—and that’s the least interesting thing about you, too.
Everyone gets knocked down sometimes; only people like you get back up again and keep going.
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Your perspective is refreshing.
You’re more helpful than you realize.
Is that your picture next to “charming” in the dictionary?
You look great today.
These compliments focus on how the person relates to others.
You’re wonderful.
You’re a gift to those around you.
Your smile is contagious.
How is it that you always look so great, even if you’re in ratty pajamas?
I bet you make babies smile.
Your eyes are breathtaking.
Is that your picture next to “charming” in the dictionary?
On a scale from 1 to 10, you’re an 11.
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You’re a smart cookie.
Complimenting Accomplishments
You light up the room.
You are enough.
Your name suits you to a T.
Your bellybutton is kind of adorable.
You are the most perfect you there is.
You’re all that and a super-size bag of chips.
You’re more helpful than you realize.
Your bellybutton is kind of adorable.
You’re all that and a super-size bag of chips.
You look great today.
You have the best laugh.
Is that your picture next to “charming” in the dictionary?
You’re a smart cookie.
You have the best laugh.
You have the best ideas.
You should be thanked more often. Thank you.
You should be thanked more often. Thank you.
You’re like a breath of fresh air.
You have impeccable manners.
You’re an awesome friend.
You’re more helpful than you realize.
How do you keep being so funny and making everyone laugh?
You’re strong.
Your name suits you to a T.
When you’re not afraid to be yourself, that’s when you’re incredible.
How is it that you always look so great, even if you’re in ratty pajamas?
You’re strong.
On a scale from 1 to 10, you’re an 11.
You’ve got all the right moves.
On a scale from 1 to 10, you’re an 11.
You are making a difference.
Everyone gets knocked down sometimes; only people like you get back up again and keep going.
Actions speak louder than words, and yours tell an incredible story.
How do you keep being so funny and making everyone laugh?
You have impeccable manners.
You should be thanked more often. Thank you.
How is it that you always look so great, even if you’re in ratty pajamas?
You could survive a zombie apocalypse.
Complimenting Personal Traits
Who raised you? They deserve a medal for a job well done.
I bet you sweat glitter.
I appreciate you.
Your creative potential seems limitless.
You’re a great listener.
Colors seem brighter when you’re around.
You may dance like no one’s watching, but everyone’s watching because you’re mesmerizing.
You were cool way before hipsters were cool.
These compliments acknowledge different qualities the person exhibits.
You’re an awesome friend.
You light up the room.
If cartoon bluebirds were real, a couple of ’em would be sitting on your shoulders singing right now.
Complimenting Personal Relationships
You’re inspiring.
You were cool way before hipsters were cool.
Complimenting Accomplishments
Everything would be better if more people were like you.
You’re like a breath of fresh air.
Our community is better because you’re in it.
Your smile is contagious.
So that your picture next to “charming” in the dictionary?
I bet you sweat glitter.
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You’re strong.
Everything would be better if more people were like you.