New file layouts, test procedures call for vigilance in preparing for CMS audits

Posted by Tom Delegram, Advisory Managing Director, Deloitte & Touche LLP,  and Jack Scott, Advisory Managing Director, Deloitte & Touche LLP on August 1, 2016

Health plans that participate in the Medicare Advantage (MA) and Part D programs should already be preparing to adapt to a large number of potential changes to the data and testing protocols the Centers for Medicare and Medicaid Services (CMS) uses during its audit process. CMS released the draft 2017 audit protocols in June 2016 and the comment period for the proposed changes extends until August 12, 2016. The rules may not become final until late in the calendar year, but there are steps plans can take now that will help them prepare for the 2017 audit season.

As proposed, the changes include two major categories: data structure across all audit protocols and testing procedures. Changes include but are not limited to:

  • File layouts for Organization Determinations, Appeals, and Grievances (ODAG), Coverage Determinations, Appeals, and Grievances (CDAG), Formulary Readiness (FA), and Special Needs Plans (SNP) would all see some change s, principally in the form of new data fields.
  • FA would add a new table for rejected claims, and ODAG and CDAG would add new tables for customer call logs.
  • Compliance standards for ODAG and CDAG would change for denials, dismissals, withdrawals and re-openings and in response to the new tables implemented for rejected claims and customer call logs
  • ODAG and CDAG testing would both add 10 “grievance samples” from their call log universes to identify misclassification of requests.

Each of these changes has its roots in a push to improve the efficiency and accuracy of the audit process. For plans, however, the immediate question isn’t as much “why” as “what” – less the nature of the changes, and more the number of them.

The new audit protocol details are likely to require plans to make internal changes to their compliance standards. Their data structures and monitoring programs may need to adapt in ways that are as numerous as the protocol updates themselves, even if each change appears minor. Many of the necessary adaptations are unlikely to change between now and when the protocols become final.

What can plans do now? They can make sure all internal players are meeting and planning cross-functionally so their organizations bring a unified effort to the change. They can also start programming in the testing environment, pulling data into the proposed new layouts, and conducting mock audits of their own. Deloitte Advisory will continue to monitor for the final protocol changes, and is ready to support plans in their ramp-up efforts.


This publication contains general information only and Deloitte Advisory is not, by means of this publication, rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This publication is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor.

Deloitte Advisory shall not be responsible for any loss sustained by any person who relies on this publication.

About Deloitte

As used in this document, “Deloitte Advisory” means Deloitte & Touche LLP, which provides audit and enterprise risk services; Deloitte Financial Advisory Services LLP, which provides forensic, dispute, and other consulting services; and its affiliate, Deloitte Transactions and Business Analytics LLP, which provides a wide range of advisory and analytics services. Deloitte Transactions and Business Analytics LLP is not a certified public accounting firm. These entities are separate subsidiaries of Deloitte LLP. Please see http://www.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

Copyright © 2016 Deloitte Development LLC. All rights reserved.

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