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Spring Conference 2012 Audit Strategy and Audit Process

Spring Conference 2012 Audit Strategy and Audit Process. Tawanda Holmes, Director Division of Compliance and Policy Operations & Jonathan Blanar , Deputy Director Division of Compliance and Policy Operations Program Compliance and Oversight Group Center For Medicare April 11, 2012.

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Spring Conference 2012 Audit Strategy and Audit Process

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  1. Spring Conference2012 Audit Strategy and Audit Process Tawanda Holmes, Director Division of Compliance and Policy Operations & Jonathan Blanar, Deputy Director Division of Compliance and Policy Operations Program Compliance and Oversight Group Center For Medicare April 11, 2012

  2. CMS Perspective (Goal & Initiatives) • Best Practice Reviews of 5-star Plans • Publish Findings and Best Practices • Publish CMS Audit Protocols • 2012 Audit Strategy • 2012 Audit Process

  3. 2012 Audit Strategy • Audits will evaluate plans’ compliance with program requirements and determine if beneficiaries have adequate and appropriate access to care • Conduct 30 – 40 Audits in 2012 (compliance program onsite, other areas mostly virtual) • Outcome based approach • Ensure non-compliant issues are corrected

  4. 2012 Audit Strategy • Key Performance Audit Areas: • Part D Formulary • Part D Coverage Determination, Appeals, and Grievances • Part C Access (Complaints) • Part C Organization Determination, Appeals, and Grievances

  5. 2012 Audit Strategy • Key Performance Audit Areas (continued) • Enrollment/Disenrollment • Late Enrollment Penalties • Compliance Program • Agent/Broker Oversight

  6. 2012 Audit Strategy • 5 Categories for Selecting Sponsors for Audits: • Good Performers (high star rating) • Poor Star Performers (< 3 stars for over 3 years consecutively) • Middle of the road (average or declining performance) • Worst performers (high risk via risk assessment) • Sponsors not otherwise selected will be audited within 5 years

  7. 2012 Audit Process • Objectives: • Educate the Sponsor on what they can expect if they are selected for audit • Walk through the 3 phases of the audit process • Pre Audit • Audit (Onsite and Webinar) • Post Audit

  8. Audit Process Timeline – Key Activities

  9. Pre Audit An Example of the process for an audit scheduled 4/30 – 5/4: 4/2/12: • Engagement Letter Sent to SO – The PCOG AL sends an audit engagement letter to the SO four weeks prior to the first day of the on-site visit. • Areas for audit • Logistics (i.e. webinar, onsite, etc.) • CMS requirements with regards to facility/records access, information needed prior to the audit, on-site space requirements, key personnel and system requirements, webinar ability, etc. • Universe requests and universe templates

  10. Pre Audit 4/4/12: • Follow-Up Call with the SO – The PCOG AL conducts a follow-up call with the SO and the audit team(s) 1-2 days after the date of the engagement letter • The purpose of this call is to discuss: • Audit process • Timelines • Access to Secure File Transfer Portal (SFTP) for Universes • Address sponsors questions

  11. Pre Audit 4/4/12-4/6/12: • Setup Webinar for Audits – Either use the SO webinar if available or use CMS webinar resources. CMS and the SO will test the webinar to ensure functionality prior to the start of the audit 4/13/12: • Data Requests – Within 10 business days of receiving the engagement letter the SO uploads all requested data (i.e., universes) letter to SFTP per instructions provided by the AL 4/13/12-4/27/12: • CMS Review Data Submissions by the SO - CMS will review the data for completeness and then select a sample. The sample size depends on the area for audit

  12. Audit (Webinar and Onsite) • Who will be onsite and how many people will be onsite? • PCOG Audit Lead • Compliance Team – about 4 people • Total onsite at SO = about 5 people

  13. Audit (Webinar and Onsite) 4/30/12: • Audit Begins: • Audit Areas Via Webinar: • Part D Formulary Administration • Part D Coverage Determinations and Appeals • Part D Grievances • Part C Organization Determinations and Appeals • Part C Grievances • Agent/ Broker Oversight • Enrollment/ Disenrollment • Late Enrollment Penalties (LEP) • Part C Access to Care (Complaints) • Audit Area Onsite at SO • Compliance Program Effectiveness

  14. Audit (Webinar and Onsite) 4/30/12: • Entrance Conference – The review starts with an entrance conference held the morning of the first day facilitated by the PCOG AL The purpose of this conference is to make introductions, review the CMS audit approach and expectations, allow the Sponsor to present their operations, and address questions

  15. Audit (Webinar and Onsite) 4/30/12-5/4/12 (may extend into week of 5/7/12): • Conducting the audit – TLs conduct the audit using audit protocols and an associated Method of Evaluation (MOE) • Samples Given to SO – The TL will upload the samples to the SFTP usually the first day of the audit. Some samples may be given at a later point in the week depending on the area • Audit Process for On-Site at the Physical Site SO – CMS Compliance auditors conduct interviews, operations and system walkthroughs, and review selected samples with the Sponsor • Audit Process for Virtual Access – CMS conducts the audits virtually through the use of secure webinar technology. SO are expected to be able to walk CMS through sample cases live in their systems

  16. Audit (Webinar and Onsite) 5/4/12 (or when audit ends): • Exit Conference – After all audit areas are completed, the PCOG AL conducts an exit conference with the SO to provide preliminary results and next steps. The SO is afforded the opportunity to ask questions about the results and audit findings and provide any follow-up information as appropriate • Goal is to be 100% transparent with the SO. • There should be NO SUPRISES at the exit conference

  17. Post Audit 6/1/12: • Draft Audit Report Preparation and Issuance to SO – CMS will issue a draft report to the SO (goal is within 1 month of the conclusion of the audit) 6/8/12: • SO Responds to Draft Report - The SO will have 5 days to provide comments to CMS on the draft report

  18. Post Audit 6/22/12: • Issuing the Final Audit report and Corrective Action Requirement(s) – CMS will issue a final report (goal is within 2 weeks of receiving the SO comments on the draft)

  19. Post Audit 9/24/12: • Corrective Action Monitoring and Validation – The SO generally has 90 days to provide CMS with an attestation that all identified deficiencies have been corrected. Once the corrective action summary and attestation are received, CMS will validate correction by “re-testing” the areas found to be problematic. This will include pulling a new universe and selecting samples for testing. The regional office will lead this effort Closing the Audit: • Once it is determined that all deficiencies have been corrected, the audit is closed. The PCOG AL will coordinate with the regional office to draft an audit Close-Out Letter. If issues remain, the regional office will recommend next steps (i.e. non-compliance letter, warning letter, etc.)

  20. Questions Contact Information Tawanda.Holmes@cms.hhs.gov Jonathan.Blanar@cms.hhs.gov

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