CMS Changes to 2019 Audit Protocol: What You Need to Know

Pharmacy teams can now expect their drug management programs to fall under considerable audit scrutiny by the Centers for Medicare and Medicaid Services regarding a new federal law that aims to prevent prescription opioid misuse and addiction.

For the first time, CMS will look at health plans’ implementation of the Comprehensive Addiction and Recovery Act throughout the program audit process.

The agency released the change as part of its 2019 audit protocols.

CMS releases changes and updates to its program audit process every year so health plans know what to expect in the event they are audited. Such probes include CMS program audits, PDE audits, one-third Financial audits, BID audits, Formulary Administration audits, Transition Monitoring Program Analysis, Coverage determination/redetermination Timeliness audits and Data Validation audits.

Medicare plans are increasingly subject to closer CMS monitoring and review. An audit is more likely now than ever before.

Be Prepared 

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.

The next audit notifications will be sent between March and July.

Fewer Deliverables

The CMS changes to audit protocols include some positive news for health plans – including a reduction in audit deliverables. For example, health plans are no longer required to submit Call Logs and answers to supplemental questions during a program audit. CMS has suspended:

  • The collection of CDAG, ODAG, and SARAG Supplemental Questions at the time an audit engagement letter is drafted. Instead, CMS is encouraging plans to use the questions as a guide to determine non-compliance.
  • The collection of Call Logs, which help identify misclassification of coverage requests during the Compliance Program Effectiveness portion of an audit. The agency plans to use other ways to look at requests that are filed incorrectly, such as reviewing how well a plan oversees the call-routing process.
  • The collection of certain CPE data and documentation that can be obtained elsewhere.
  • The collection of Formulary and Benefit Administration and Special Needs Model Plan of Care enrollment verification evaluation.

CMS also has decided to make three CPE universe data fields optional: CPE FTEAM Column C, FTE Contract Effective Date; and CPE ECT Columns I and J, “Medicare Compliance Department Employee” and “Compliance Department Job Description.” The agency determined each played an insignificant role in determining non-compliance.

CMS also says it will take a broader look into the misclassification of calls as well as compliance and oversight of call routing.

The Bottom Line 

Many of the changes for 2019 will reduce the burden on health plans. Others are challenging. Plans should take steps to address the changes and plan for an audit that is likely coming – this year or down the road. We can help.

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.

Drop us a note at Let’s get connected.