CMS Program Audit Protocols

2015/2016 CMS Program Audit Protocols and Process Updates

CMS program audit evaluate the performance of the Medicare Advantage/Prescription drug plans (MAPDs) and prescription drug plans (PDPs) that provide health care coverage to Medicare eligible beneficiaries. In February of 2015 CMS published the audit protocols that will be utilized … Read More

CMS Program Outreach

Reasonable Outreach: Are you missing what CMS expects?

The Centers for Medicare & Medicaid Services (CMS) on April 20th of 2016 released several job aids in order to assist plan sponsors with improving their operations and ensuring compliance with CMS requirements. These job aides are based on common … Read More

Appeals and Grievances Process

How To Optimize your Appeals and Grievances Process?

When it comes to appeals and grievances process, most healthcare organizations struggle to improve compliance, productivity, visibility, and ratings while lowering penalties. Steps to optimize your Appeals and Grievances process: Make reaching out to complain a child’s play: Complaints are … Read More

Americans with Disabilities Act (ADA) Changes

I attended a call recently with CMS and the ADA, CMS is looking to adhere to the Americans with Disabilities Act (ADA), when it comes to assessing monetary penalties to health plans that are not providing information in an alternative … Read More


CMS Audit Universes as a Tool for Ongoing Compliance Monitoring

One of the most arduous and time-consuming activity for MAPD and PDP plans is the creation of the required universes for CMS Audit submission. Health plans often struggle with the critical step of universe creation followed by ensuring that the … Read More