CMS releases final Medicare audit protocol updates

The Centers for Medicare and Medicaid Services (CMS) has released the final protocols for 2017 audits of Medicare Parts C and D plans. This is the latest step in a process RegPulse has reported on during the initial release and as draft protocols underwent updates during the last year.

The audit protocol revisions affect the ways in which plan sponsors—such as Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), and Medicare-Medicaid Plans (MMPs)—prepare and present information about their data universes to CMS. Sponsors that take part in these programs should review the changes and continue or update their programs assessments to identify the changes that affect them and plan appropriate responses.

Here is a summary of the relevant changes to the audit protocols in the final release, listed by program type:

Compliance Program Effectiveness (CPE)

  • In data universe preparation and submission and with respect to Appendix A (record layouts), CMS will no longer allow Comma Separated Values (.csv) file formats for submitting universes into the system of records. Plans that have submitted .csv files in the past will need to pull and submit universes using an Excel or Text file format. Plans should confirm their ability to submit the universe in Excel or Text file format and make updates as needed.

Formulary Readiness (FA)

  • The change described above regarding .csv values and Excel and Text formats applies.
  • Instead of using rejected claims from either the new contract year or the previous one in testing prescription drug event (PDE) transitions, CMS will use To comply, plans will need to update their internal procedures for generating FA Universe Table 4.
  • For submissions when no national drug code (NDC) is available, plans should include the 11-digit value submitted by the pharmacy, and when multi-ingredient compound claims do not include any Part D drug products, plans should populate the field with 11 zeroes.
  • Each pharmacy code on a rejected claim should be paired with the relevant pharmacy message, and if a claim includes multiple reject codes and multiple messages that aren’t explicitly paired, each code should be accompanied with all the messages. If a code is generated without a message or vice-versa, the plan should put “NA” in the empty field.

Coverage Determinations, Appeals, and Grievances (CDAG)

  • The change regarding .csv values applies to CDAG as it does to CPE and FA.
  • Plans with fewer than 50,000 enrollees should submit calls within the first four weeks of the audit review period. Earlier drafts of the protocols specified two weeks.
  • Plans with more than 250,000 enrollees should submit calls within the first two weeks of the audit review period. Earlier drafts of the protocols specified four weeks.

Organization Determinations, Appeals, and Grievances (ODAG)

  • The change regarding .csv values applies here as in the other categories.
  • In Table 10, Request for Expedited Timeframe, the field will now accept a second character, to make “NA” responses possible. Plans should update their universe generation logic to account for this option.
  • A correction specifies that in Table 14 on “First Tier, Downstream, and Related Entities” (FDRs), plans should submit the name of the FDR that processed the call, not the entity that processed the dismissal.
  • CMS has added additional types of requests to be excluded from the universe. Plans should decide whether or not they will update their universe generation coding to support these additional exclusions, and update the logic they use to generate the all affected ODAG Tables to reflect new exclusions. Note that CMS has indicated they will accept submissions in instances where the programming was already completed. Plans should review procedures and capabilities to make sure additional exclusions can be easily identified.

Special Needs Plans Model of Care (SNP-MOC)

  • The change regarding .csv values applies here as in the other categories.

Medication Therapy Management (MTM)

  • The change regarding .csv values applies here as in the other categories.

Authors:

Jack Scott
Manging Director | Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

Tom Delegram
Manging Director | Deloitte Risk and Financial Advisory
Deloitte & Touche LLP

1, 2 CMS Press Release

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