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2023 Program Audit Updates

Updated: Jan 4, 2023


Updates To The 2023 CMS Program Audit

On November 30, 2022, The Centers for Medicare and Medicaid Services released an HPMS memo regarding updates for Program Audits for the 2023 Contract Year.


CMS will continue to use the current Final Audit Protocols (CMS-10717) for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project, and the 2022 MMP Audit Protocols and Data Requests to conduct 2023 program audits.


What's New That You Should Be Aware Of?

A slight change to the coming program year is CMS’s added interest in reviewing requirements not specifically addressed in, but related to, the protocol. CMS highlighted its 2019 final rule (CMS-4185-F) as an example of related requirements, notably, the provisions requiring all Dual Eligible Special Needs Plans (D-SNPs) to assist enrollees with Medicaid coverage issues and grievances, including authorizations for, or appeals related to, Medicaid-related services, in addition to establishing new standards for integration of Medicare and Medicaid benefits for D-SNPs that improve care coordination, beneficiary satisfaction, and the reduction of administrative burden.


What Are in The CMS Plans?

CMS plans to review how D-SNP sponsors have implemented these requirements in an effort to understand how enrollees are provided the assistance prescribed in these regulations. More broadly, the 2019 Final Rule implemented certain provisions of the Bipartisan Budget Act of 2018 and aimed to improve MA and Part D program quality and accessibility, and clarify program integrity policies.


CMS unified Medicare and Medicaid grievance and appeals processes for certain D-SNPs and affiliated Medicaid managed care plans with a stated goal of creating and simplifying a straightforward grievance and appeals processes. Compliance with the unified grievance and appeal procedures was required beginning in CY 2021.


CMS also stated they will continue to explore opportunities to respond to stakeholder feedback received on the program audit process and specifically cited the formulary administration protocol whereby CMS will analyze prescription drug event (PDE) data to determine if it can be used instead of the current FA Table 3 (Prescription Drug Event) in future audit years. It is imperative to oversee the submission of your plan’s PDE data and the timely correction of PDE errors.


With the issuance of this HPMS memo, CMS also announced the publication of its broader Program Audit Process Overview document, which is now available on the CMS website. That document remains largely unchanged from 2022 with some limited exception including CMS’s removal of 2022 language whereby they reserved the right to request CAPs for observations. While this does not necessarily mean that CMS will not request CAPs for observations, it is an element of the audit process to keep an eye on. Otherwise, organizations should again expect scheduled program audit engagement letters between February and July 2023.


Are You Prepared?

For additional information about the recently issued memo, to learn more about the 2019 final rule, or for any support with audit readiness including review of your plan’s PDE processes, please contact the Rebellis Group at contactus@rebellisgroup.com


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