CMS Audit Success: Compliance Matters

Mar 28, 2017
Strong compliance is an indication of high quality, excellent service and optimal health outcomes for members.
  • Medicare
  • Seniors

Kyle Shayna Article

Non-compliance is not an option for Medicare Part D plans. And the monetary penalties can add up for those plans who do not meet The Centers for Medicare and Medicaid Services (CMS) performance standards.

CMS calculates audit scores using the number of immediate corrective actions compared to the total number of audited elements. The lower the program audit score, the better the plan performance on the audit.

When CMS finds performance standards are not met, particularly when the non-compliance adversely affects enrollees, they can levy civil monetary penalties (CMPs). Since 2010, CMS has levied more than $28 million in CMPs. Just last year, CMS published a methodology for calculating CMPs based on CMS program audits with an opportunity for the industry to comment.

Unfortunately, the methodology does not address CMPs that may be levied for compliance actions taken outside of a CMS Program audit. From the data available, plans are subject to tight scrutiny with an average of 14 receiving some CMP each year though it has ranged from as few as 7 to has high as 26. In the last 37 audits, 17 received a CMP.

Audit findings also require corrective actions and ultimately result in the publication of best practices by CMS. Successful plans know that implementing these best practices will position them for success in the next CMS program audit.

The Right Partner

Compliance support is a major component in the services Express Scripts provides to our Medicare Part D clients, and our knowledge, expertise and data solutions help clients achieve optimal CMS compliance. In 2016, Express Scripts supported ten program audits in 2016 with audit scores below the industry average, a good thing for our clients. Our team analyzes more than 100 metrics on a monthly basis to deliver monthly leadership reports and identify opportunities for continuous improvement. Our dedicated Government Audit team continues to assure consistent delivery of audit materials and proven processes for support during the audit. Lastly, Medicare subject matter experts continue to advise clients throughout the year so they are fully prepared when the audit notice arrives.

Compliance with CMS regulations is good business for Medicare Part D plans. Audit scores aside, strong compliance is an indication of high quality, excellent service and optimal health outcomes for members.

It does take a significant investment from Express Scripts and our clients to support Medicare Part D compliance, but the results are worth it: low audit scores, fewer compliance actions, higher-than-average star ratings, satisfied beneficiaries, and overall success in this competitive marketplace.

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