On July 18, 2023, the Center for Medicare and Medicare Services (CMS) released the “2022 Part C and Part D Program Audit and Enforcement Report,” providing the details of the 2022 audit cycle.[1] Elixir’s Compliance Team summarized the report, which provides analysis and information for plan sponsors and stakeholders to review in their continuous improvement efforts within their organizations.
Audits: 26 program audits across 25 separate parent organizations
Beneficiaries: ≈ 33.6 million (63%) Part C and Part D enrolled beneficiaries
Contracts: 291 (29% of total) Part C and Part D contracts
The 2022 report:
The CMS report outlines general 2022 noncompliance activities and recommends actions for improvement. CMS also restates the general expectation that plan sponsors carefully and routinely assess all risks to their organizations and monitor and audit their operations to ensure compliance with CMS requirements. CMS cautions against using the 2022 enforcement report to draw broad conclusions about the significance of deficiencies, noncompliance or overall industry performance across the Medicare Advantage, Part D, or Medicare Medicaid Plan (MMP) programs. Below is a high-level summary of audit insight related to Part D plans.
CMS recommendation for improvement: Plan sponsors should evaluate work instructions for clarity, make updates as necessary, and enhance training related to prevention, detection and correction of noncompliance. Plan sponsors should also update auditing and monitoring plans to align with updated CMS regulations.
CMS recommendation for improvement: Plan sponsors should tailor their monitoring of rejected claims to identify patterns and reveal errors in system edit configuration.
CMS recommendation for improvement: Plan sponsors should refer to the compliance standards in CMS audit protocols to understand how CMS assesses timeliness requirements during program audits.
To support an efficient and effective audit experience, Elixir's Compliance, Clinical Audit, Government Programs, Formulary, and CDAG teams actively engage our clients before, during and after CMS audits, including program, financial and operational audits. This collaboration between a plan and the PBM is critical to the success of a program and is a cornerstone of how Elixir works with our clients.
[1] Centers for Medicare and Medicaid Services (2023). 2022 Part C and Part D Program Audit and Enforcement Report https://www.cms.gov/files/document/2022-program-audit-enforcement-report.pdf