MAOs May Face More Aggressive CMS as Audits 'Return to Normal' in 2021

by Lauren Flynn Kelly

The Trump years were noticeably light on Medicare Parts C and D program enforcement, but as CMS resumes program audits and other oversight activities this year, Medicare compliance experts are advising plans to review key business functions.

CMS last March suspended scheduled program audits of Medicare Advantage organizations, Part D sponsors, Medicare-Medicaid Plans and Programs of All-Inclusive Care for the Elderly to shift its oversight focus more directly on assuring the delivery of care during the COVID-19 pandemic. The agency in July restarted program audits on a condensed basis and in a Dec. 23, 2020, memo said it expects to "conduct routine audit activities" for Parts C and D sponsors in 2021.

In other words, CMS appears to be moving "back to normal…and our view is that a lot of plans are out of practice preparing for audits," says Steve Arbaugh, CEO of ATTAC Consulting Group (ACG). On top of the fact that plans aren't audited every year and many haven't been audited for several years, "the fact that they were occupied with other issues during 2020 [raises the question of] whether they've maintained the rigorousness of testing their data, their performance and so on, so we would suggest they look at testing, preparing, and audit readiness."

Amanda Brown, vice president of Compliance Solutions with ACG, says the firm's audit work shows that plans continue to struggle with compliance in certain areas, including the appropriate classification of grievances and oversight of first-tier, downstream and related entities.

Regarding oversight of FDRs, one emerging area that is likely to face more scrutiny is telehealth. ACG notes that the Office of Inspector General has seen telehealth vendors use enrollee data inappropriately.

"Another area that is difficult for many plans to get their arms around is what we call plan-directed care issues," which relates to how plans link authorizations in their claims systems, adds Arbaugh.

In a recent brief from the KPMG Center for Healthcare Regulatory Insight, the consulting firm suggested "it is likely that the Biden Administration will pick up where the Obama Administration left off and use its administrative authority to more aggressively monitor Medicare regulatory requirements on private plans, which could lead to more regulatory enforcement and civil monetary penalties (CMPs) to support program integrity in the Part C & D programs."

From RADAR on Medicare Advantage