The 2021 audit cycle is coming to a close. The Centers for Medicare and Medicaid Services (CMS) issued its last engagement letters for 2021 program audits at the end of July. Field work is complete and the audits are in their final phases of reporting, validation and close out. We will provide a review of the 2021 audit enforcement report upon its release.
CMS did release its summary of 2021 Data Validation Audits in September.[1] Although CMS does not publish plan-specific results, mean scores were all above 99%, and this is consistent with the very strong results Elixir’s clients received for those who have shared their findings.
Portal to the Future
Also in September, CMS launched the Payment Recovery Information System (PRIS) Plan Portal,[2] which will be used for future audit communications and data transmissions between CMS and plan sponsors. Plans were provided with guidance to establish an Identity Management (IDM) User ID and an External Point of Contact (EPOC) who will approve requests from their respective plan users to access the PRIS Plan Portal application.
The PRIS Portal will not be used for any audits currently in process, but will be phased in beginning with Self-Audits like those initiated this year for immunosuppressants, Xyrem®, Nuedexta®, end-stage renal disease (ESRD) and durable medical equipment (DME). CMS has not initiated any additional Self-Audits since the review of immunosuppressant drugs announced in June, but the creation of the PRIS Plan Portal indicates that CMS will continue to initiate Self-Audits. Going forward, CMS will reach out to plans that are selected for a Self-Audit to advise them of the audit and next steps.
In the next application release, all new Self-Audits, National Audits and Program Integrity (PI) Audits will be conducted using the PRIS Plan Portal. CMS will issue a series of communications to advise plans of new features, trainings and other pertinent information for the PRIS Plan Portal.
Preparing for 2022
CMS issued the contract year (CY) 2022 Readiness Checklist on October 8.[3] The Readiness Checklist is intended as a tool for plan sponsors and their partners to use in preparation for the new contract year. As is the case each year, a number of checklist items relate to PBM delegated functions and Elixir is finalizing the PBM response for delivery to clients on or before November 19. In addition, Elixir is implementing universe reporting updates and preparing for release of the 2022 program audit overview from CMS, which will define the 2022 program audit engagement time period.
[1] HMPS Memo: Results of the 2021 Part C and D Reporting Requirements Data Validation. September 23, 2021.
[2] HPMS Memo: Payment Recovery Information System (PRIS) Medicare Parts C & D Plan Portal (PRIS Plan Portal) Launch. September 8, 2021.
[3] HMPS Memo: 2022 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, Medicare-Medicaid Plans, and Cost Plans. October 8, 2021.
