Audit season is upon us. As hospitals wrap up the first quarter of 2018, the Centers for Medicare and Medicaid Services (CMS) send out letters in March for program audit engagement. We review what providers should expect, and how the 2018 CMS audits will be different from 2017.

2018 CMS audits

It’s now time for the 2018 CMS audits, find out what changes to expect.

What changes have been made to the audits in 2018? 

As CMS is sending program audit engagement letters, plans may have noticed that the changes from the 2017 to 2018 protocols are minimal. As CMS enters the last year of the current audit cycle (2015-2018), plans continue to struggle with the same common conditions these practices were designed to improve according to a recent article from BluePeak Advisors.

Changes from the 2017 to 2018 CMS program audit protocols include:

  • Coverage Determinations Appeals and Grievances (CDAG), call log submissions, and Organization Determinations Appeals and Grievances (ODAG) are fewer and also based on the enrollment as follows:
    • Less than 50,000 enrollees = ten days of calls
    • 50,000 – 249,000 enrollees = seven days of calls
    • 250,000 or more enrollees = three days of calls
    • Medicare-Medicaid Plans (MMPs) = ten days of calls, regardless of enrollment
  • Fieldwork, which encompasses the operational audit webinars and onsite Compliance Effectiveness (CPE) audit has increased from two weeks to three weeks in order to provide more time for plans to make preparations for the CPE audit which now takes place during week three. Week one still includes the operational audits, such as CDAG, ODAG, Special Needs Plan-Model of Care (SNP-MOC) and Formulary Administration (FA).
  • Week two will include audit areas, such as MMP, for plans that have five or more areas.
  • The 2018 CMS Program audits have removed the Medication Therapy Management (MTM) pilot program area. Data that has been gathered from the previous two years is currently under review by CMS so plans should continue to monitor MTM processes in case this particular area is under focus in audit programs in the future.
  • Previously a pilot program, the MMP audit is now fully operational and also includes Care Coordination Quality Improvement Program Effectiveness (CCQIPE) and the Service Authorization Requests, Appeals and Grievances (SARAG) audit areas.
  • Audit engagement letters for the 2018 program will be sent out by CMS through September. Targeted audit engagement letters can be sent out at any random time.

Physicians May Notice a Less Punitive Approach to CMS Audits in 2018

Among the changes to watch for in the CMS audits in 2018, is that CMS is taking less of a punitive approach, and more of an educational approach, when it comes to Medicare billing errors.

Monthly meetings have been held by CMS and the American Medical Association (AMA) where discussion focused on the concerns regarding the Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) and suggested improvements.

History suggests these meetings are fruitful and result in serious changes. In the past, the AMA-suggested changes that CMS implemented included:

  • RACs to have medical directors
  • Certified coders
  • Web presence where doctors can look at their audits’ statuses
  • If an appeal is lost, the RAC contingency fees must be paid back

In a press release from the AMA earlier this year, changes that may be less punitive in the 2018 CMS audits are:

  1. RAC must send out the audit results to the providers in the audit before sending them to CMS.
  2. Physicians are given a 30-day window in which time they are allowed to discuss the results of the audit and submit further information or documentation supporting how they interpret Medicare requirements.
  3. Physicians may request to speak with the medical director of the RAC, the physician that reviewed the file, and a RAC physician in their own specialty. This type of communication may save physicians the time, expense, and effort of a formal appeal process. Furthermore, on a longer timeline, CMS will potentially identify the recurring areas of problems to improve the entire process.

 The recent rise in regulatory and commercial payer audits threatens providers’ revenue and creates costly administrative burdens for facilities. With SSI Audit Director, providers can ensure timely filing with a workflow tool that tracks existing, and incoming audits and protects revenue with complete visibility into audit-associated revenue risks. By adopting an offensive approach to the audit process, healthcare organizations can conquer audits and minimize the impact on their bottom line.