The Centers for Medicare and Medicaid (CMS) audit season is upon us reminding health plans that it’s a good time for an internal review. Take a look at policies and procedures and their application in practice. This includes internal policies and procedures and your health plan’s pharmacy benefit manager’s (PBM) policies and procedures if they are delegated to handle your coverage determination and redetermination reviews.
Becoming “audit ready” allows the health plan to be more confident and organized before an actual program audit. Part D audit findings in recent years have included sanctions for findings related to coverage determinations (CD) and redeterminations (RD), transition, and formulary. Common findings include the failure to properly administer the CMS transition policy, misclassification of CDs and RDs as grievances and/ or customer service requests, failure to initiate coverage determinations, failure to process reimbursement requests as coverage determinations, and failure to demonstrate sufficient outreach to prescribers or enrollees to obtain additional information. Formulary findings include inappropriately rejecting formulary medications due to errors with eligibility files, and failure to properly administer the CMS approved formulary by applying unapproved utilization management (UM) edits. Additional findings included charging incorrect copayments to enrollees in the catastrophic coverage phase, and failure to adjudicate claims properly for Low-Income Subsidy (LIS) individuals during the deductible and coverage gap phases.
Rebellis Group has experienced subject matter experts who can assist your team with an in-depth mock audit to determine potential gaps and support if you receive a CMS audit notice. Contact us at firstname.lastname@example.org or 970-481-5407.