Hurdles for Medicare Plans Posed by 2014 Audit Requirements

Background: One of the audit areas causing the most difficulty for Medicare Part D plans is coverage determinations and appeals. The recent changes, including the addition of a new "timeliness test," will continue to pose challenges for Medicare Part D plans. Objectives: To outline the potential areas of risk for Medicare Part D plans as a result of the 2014 Coverage Determination and Appeals (CDA) audit changes, in addition to defining the resultant implications to plans and describing the cascading effect of a poor CDA audit. Description: Medicare Part D plan managers will need to be aware of the new changes to the CDA audit protocols and prepare accordingly to handle the challenges with data collection, data integrity, case timeliness, and appropriate clinical decision making. Failure of an audit could result in numerous short-and long-term implications for a plan including, but not limited to, corrective and other oversight actions, civil monetary penalties, and increased remediation costs. Conclusions: Medicare Part D plans need to be prepared for the new hurdles and raised stakes that the 2014 CDA audit protocols pose. Failure to do so could result in a much larger, cascading impact than audit failure alone.