Medicare Plans Face New Oversight and Scrutiny From Audit Changes

Background: Generally, Medicare Part D plans have experienced challenges both before and during a CMS audit. The recent changes to the audit protocols will place additional stress on Part D plans. Objectives: To outline the key changes of the 2015 Medicare Part D audit process that will likely challenge Part D plans, and to define the potential consequences for plans failing to comply with audit protocols and fulfill new CMS expectations. Description: Part D plans will need to analyze the changes to the Part D audit protocols and make adjustments accordingly to meet the challenges with universe format changes, the addition of new data elements and questionnaires, new record layouts, accuracy of the universe submissions, pre-audit issue summaries, and beneficiary impact analyses. Failure to comply with protocols and meeting CMS' expectations could have serious ramifications including, but not limited to, mandatory corrective actions, multiple immediate corrective actions (possibly stemming from a single source of data inaccuracy), civil monetary penalties, additional compliance enforcement actions, and substantial remediation costs. Conclusions: The new protocols require diligent preparation if Medicare Part D plans are to meet CMS' higher expectations and perform well during a program audit. Plans failing to preparesuch as taking the necessary steps to test completion of the new universe formats and validate for data accuracy-increase their risk of being cited for poor performance if audited as well as increasing the chances of an audit report making critical findings, and potentially face the risk of compliance and enforcement actions.