The 2019 CMS Program Audit Season is Upon Us!
CMS started issuing audit letters in March and will continue doing so through July. If you haven't already received an audit notice, what are you doing to prepare?

2019 starts the newest Program Audit cycle and while there were minimal changes to the 2019 Program Audit Protocols, BluePeak is expecting significant changes for 2020 and will update you on those changes this Spring.

The changes to the 2019 Protocols are listed below:
  • Suspension of the CDAG, ODAG and SARAG Supplemental Questionnaires
  • Suspension of Call Log Universes for CDAG and ODAG
  • CMS will review Plan’s oversight of call routing as part of the CPE review
  • Suspension of the CPE self-assessment questionnaire
  • Removal of the Contract Effective Date in the FTEAM Universe
  • Discontinued collection of the Call Log tables, but will now analyze call routing and classification oversight in CPE
  • Removal of the following fields in the ECT Universe
  • Medicare Compliance Department Employee verification
  • Compliance Department Job Description
  • Compliance Committee Member verification
  • Compliance Committee Member’s Role
  • Suspension of the Website review in FA
  • Suspension of Enrollment Verification in SNP-MOC
  • Tracking Comprehensive Addiction and Recovery Act (CARA) beneficiary at-risk determinations in the SRD and ERD Universes
At the January 2019 Health Care Compliance Association (HCCA) Managed Care Conference, John Scott, Acting Director of Medicare Parts C and D Oversight and Enforcement (MOEG), spoke to the need for Plans to conduct mock audits to confirm preparedness for the upcoming audit season.  While CMS has not directed Plans on the use of external entities to perform mock audits, Mr. Scott cautioned Plans on using reputable advisors with substantial Medicare knowledge to assist them in audit preparations and validations. Preparing for an audit ahead of time by knowing you have good data, a strong team of internal and external partners, and support of your leadership will significantly help you as you go through an audit. 

Using Interim Staffing to bring Appeals and Grievances Timeliness into Compliance-A Case Study

Sometimes, life happens. Turnover, volume increases, changing guidance, system changes or audit issues that require remediation all can create situations where a Plan or PBM needs expert resources fast. And let’s face it: good resources with expertise in government-sponsored health care are hard to find.

BluePeak recently worked with a large MA-PD client that had significant issues with Part D coverage determinations and/or redeterminations needing to be auto forwarded to the independent review entity (IRE) due to missing decision timeframes. The Sponsor had experienced staff turnover in several key positions. Due to the gap in resources and some misunderstandings that led to process issues,, the Sponsor was misclassifying appeals, failing to submit appropriate case files to the IRE and lacked the ability to timely effectuate overturned cases.

CMS Continues Along Its Roadmap to Address the Opioid Epidemic

Effective January 1, 2019, the Centers for Medicaid & Medicare Services (CMS) required plan sponsors to implement new opioid policies as part of the agency’s continued efforts to address the nation’s opioid epidemic. CMS’ three-pronged approach involves the prevention of new cases of opioid use disorder, treatment of patients who have already become dependent on or addicted to opioids, and utilization of data to aid in prevention and treatment activities. 1

Potential Changes on the Horizon for 2020 and Beyond
After getting ready for all the changes a new contract year brings, Medicare Advantage (MA) Plans and Part D sponsors to turn their attention to the issuance of the Draft Call Letter for early indications of the next line-up of changes that may be coming their way. The recently released 2020 Draft Call Letter had a few noteworthy changes:

  Part C:
  • Additional Flexibilities on Certain Supplemental Benefits: Starting in 2020, MA Plans have new flexibilities as related to special supplemental benefits for chronically ill (SSBIC) beneficiaries, including the ability to offer cost-sharing specific to a chronic illness and the ability to offer supplemental benefits that are not primarily health related when they meet certain requirements;
  • New third maximum out-of-pocket (MOOP) limit in 2021.
Part D:
  • Further action to address the opioid crisis;
  • The Part D cost sharing out-of-pocket threshold will jump from $5,100 in 2019 to $6,350 in 2020;
  • Effective in 2019, the Transition Monitoring Program and Formulary Administration Analysis oversight monitoring projects are discontinued, and those Display Measures are retired. 

BluePeak Service Spotlight:
Universe Monitoring Service

Will sponsoring organizations always have the opportunity to submit universes up to three times during a program audit?” CMS’ response was:

“No. Three attempts may not always be feasible depending on when the data issues are identified and the potential impact to the audit schedule (e.g. sponsoring organizations will not be allowed to resubmit universes after auditors have shared timeliness test results with the sponsoring organization).”

This gives Plans yet, another reason to ensure universes are accurate.

BluePeak can review your data and coach your team to help them produce accurate and complete universes with our Universe Monitoring Services . Since 2013, BluePeak has completed over 150 CMS mock audits and onsite support projects, and we’ve observed that many plans still struggle with pulling and populating universes correctly. Plans who are unable to produce accurate and complete universes after three tries (or fewer as noted above) receive an Invalid Data Submission condition that counts toward their overall CMS program audit score.
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See Me at Annual Meeting 2019,
March 25-28
[L2] Medicare Formulary Updates Impact

The Centers for Medicare and Medicaid (CMS) continues to critically evaluate formulary regulations and guidance to help lower drug costs. This session will inform health plans, pharmacy benefit managers (PBMs) and other health care professionals about the CMS changes to Medicare Part D that will be implemented in 2019 and 2020, and their operational and financial implications.
Learn more at
Principal, BluePeak Advisors
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