CMS Releases the 2015 Audit Protocol: Critical Next Steps to Avoid Becoming A Casualty of Reasonable Expectations

On February 12th, CMS released the 2015 Audit Protocol. The question on everyone’s mind is – what does this mean for 2015? Well, it means a few things. Outlined below are some of the most impactful changes, as well as the “why” behind the change, and the trends that continue to emerge.

1. CMS has initiated a new audit cycle – this means that even if your Organization was audited in 2012, 2013, OR 2014, your Organization could be audited again this year.

2. CMS has included language with fangs around universe submission accuracy. For any Organization that has been audited in the last few years, this will come as no surprise. CMS has narrowed in on the fact that Organizations have a disturbingly hard time pulling accurate universes. The fact is that a dirty universe is a symptom of a much larger issue within the Organization – and CMS knows it. With the 2015 audit cycle, CMS will allow a maximum of three (3) attempts to submit an accurate universe. After the second failed attempt, CMS will automatically document an observation, and after the third failed attempt, the Organization will be cited an Immediate Corrective Action Required (ICAR) – for EACH condition that cannot be tested due to inaccurate universes.

3. CMS will again measure timeliness at the universe level for standard and expedited organization determinations, appeals, and grievances (ODAG) and for standard and expedited coverage determinations, appeals, and grievances (CDAG). However, in 2015, while CMS will request the same data as in past years, now each separate request will have its own universe template. What’s the relevance here? This means that any programing that your Organization completed around current universe requests must be redone. This may seem like a small thing, but with the increased focus on review at the universe level, the increased emphasis on universe accuracy, AND the historical difficulty the industry has had with pulling accurate universes – this should be top on your Organization’s list.

4. CMS has modified long-standing audit protocols such as the Compliance Program Effectiveness protocols which were “redesigned to be more outcomes focused and less burdensome”. CMS will now test all seven elements of Compliance by pulling tracer samples, which means that CMS will trace the sample through the Organization to determine compliance. The move to using the tracer sample review for all seven elements is very telling. We see here that CMS is continuing to move toward a method of results oriented review vs. a review based on Organization policy. In other words, if you can’t demonstrate Compliance, it probably doesn’t exist.

5. CMS will incorporate two pilot review areas in 2015. First, review of the Medication Therapy Management (MTM) Program, which is to be expected with CMS’ continued focus on Part D. Second, and more interesting, is the addition of the Provider Network Adequacy pilot. At first, you may wonder why CMS decided to include this out of all possible additions. Well, the answer is that CMS has become aware of issues with access to care, and these issues extend to access to physicians. In other words, your Organization must ensure that it is meeting network adequacy standards, specifically for specialty and sub-specialty providers, AND that the providers are open to treat enrollees.

As we can see from the above, CMS administrators are true to their word – CMS continues to intensify its focus on the health and well-being of the beneficiary, and they should. As John Gorman and I discussed during our webinar held on February 13th, titled, “Top 10 Things Killing Your MA Plan,” CMS continues to have a laser focus on those issues that have potential to cause imminent beneficiary harm and weeding out those Organizations that are not able to appropriately care for the Medicare population – a trend which is clear both by the continued refinement of the Audit Protocols and by a steep increase in CMS Civil Monetary Penalties and Sanction Activity.

Don’t know where to start? Contact me directly at bseals@gormanhealthgroup.com.

This blog was originally posted on blog.gormanhealthgroup.com.
John Gorman: Under John’s leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more.