The Centers for Medicare & Medicaid Services (CMS) launched a new cycle of CMS program audits in February 2022. Even though we’re six weeks from the end of the 2022 cycle, there’s still time to review the new and changed features of the CMS audit protocol (CMS 10717) for CY 2022. For an overview of the protocol changes for CY 2022, please visit our blog- CY 2022 CMS Program Audit Protocol Changes  

Today, we highlight the changes in the protocol for Organization Determinations, Appeals and Grievances (ODAG) and focus on: 

  • What to look for during an audit 
  • Best practices for ODAG 

2022 CMS Program Audit ODAG Protocol Changes 

Universe tables have been streamlined from 13 to six, but the audit elements to be tested remain the same: timeliness, processing and classification of coverage requests. However, Table 6, Dual Special Needs Plan — Applicable Integrated Plan (AIP) Reductions, Suspensions, and Terminations (AIP) — is required if the plan sponsor (Sponsor) is determined to be an applicable integrated plan and has been notified by CMS of their status. Part B drug is a new data field in Table 1 Standard and Expedited Pre-Service Requests for Organization Determinations (OD). 

 Download 2022 ODAG Audit Universe Changes 

 What to Look for During a CMS Program Audit 

CMS selects 60 targeted samples for the ODAG program audit to ensure enrollees have appropriate access to health care services and medications, and to verify Sponsors adhere to selected aspects of their contracts with CMS. Compliance Standard and Method of Evaluation are outlined in the protocol.  

CMS underscores that Sponsor has adequate process to make appropriate clinical decisions based on National Coverage Determination (NCD), Local Coverage Determination (LCD) or internal coverage policies. In our experience, several areas represent the most common risks for Sponsors in an ODAG audit: 

  1. Inappropriate denial of plan-directed care, not requiring waiver of liability (WOL) from non-contract providers (NCP) and not including appeal rights in denial notices to NCP, as enrollees may incur inappropriate out-of-pocket expenses for medical services. 

Best Practices: Claims department staff should be trained to spot plan-directed care when denying payments to NCP. WOL should be part of the denial notice to NCP, as are appeal rights. Regular monitoring of claims and denial notification can mitigate this risk. 

  1. Charging enrollees incorrect cost-sharing due to failure to update their systems with a correct fee schedule. This causes claims to providers to be paid incorrectly, which results in enrollees being overcharged for their coinsurance or delayed refund of overpayments. 

Best Practices: Downloading and updating the medical services fee schedule for in-network and out-of-network critical access hospital claims should be systematically programmed, because manual updates are time-consuming and prone to errors. Fee schedule changes are increasingly frequent. Sponsors should have an established procedure to avoid outdated fee schedules. 

  1. Inappropriate adjudication or determination for Part B drugs due to lack of coordination or oversight. In 2019, some Sponsors began applying step therapy for Part B drugs, which are covered under ODAG and Part C benefits. The look-back for Part B therapy is 365 days and the turnaround time is aligned with those for Part D (i.e., 24 hours for expedited requests and 72 hours for standard). 

Best Practices: Sponsors should document the ODAG process for Part B drugs, which typically falls under the Utilization Management department. Some Part B drugs, however, are adjudicated by Pharmacy Benefit Managers (PBMs), as they are often dispensed by a community pharmacy. Copayments for pharmacy dispensed Part B drugs should be cumulatively tracked with copayments for other Part B services so that enrollees would not pay more than their Maximum Out of Pocket (MOOP). 

To improve compliance with the Medicare rules, conduct regular monitoring as well as mock audits of claims and delegated entities, including the PBM, and ensure timely corrective actions. Please note that, when performing internal monitoring, Sponsors should practice the submission of the comprehensive universe data from delegated entities and validate their accuracy to prepare for a future audit and to ensure compliance with CMS Program Audit requirements.  

  1. Timeliness continues to be a common finding in ODAG program audits due to inadequate system support or lack of training; for Dual Eligible Special Needs Plans – Applicable Integrated Plans (DSNP-AIP), written notice of the denial must be provided within 3 days of receipt of the request. The additional 3-day allowance to deliver the written notification after providing oral notice does not apply. ODAG extension of 14 days is allowed only if it is in the interest of the enrollee. Extension is not permissible for Part B therapy. 

Best Practices: Sponsor’s tracking system for ODAG should include the notification date and time to track timeliness for all enrollee demographics, not only date and time for decision. The turnaround time for Part B drugs is applicable if the Part B drug is the primary request. Sponsors should practice extracting universe data on an ongoing basis, including quality review of output. They can send questions arising from routine practice to CMS or seek data clarification from the CMS auditors during the Webex prior to data integrity testing. 

  1. Incorrect categorization of Grievances when it was a coverage request due to inadequate training of intake staff. 

Best Practices:  Regular training of intake staff and monitoring of call logs — as well as review of grievance responses, whether verbally or in writing — so enrollees would not experience delay in access to covered benefits, and ensure every complaint is addressed in the response. We continue to see this as a vulnerability for Sponsors in ODAG. 

The success of an audit starts with Sponsor’s ability to submit accurate data, universes and supplemental documentation for review. Financial soundness and running a plan operationally with proper resources are equally important in audit preparedness. Sponsors may consider retaining consultants such as Inovaare to support their data extraction practice or to conduct mock audits. Inovaare has a team of specialists and system applications to help Sponsors scrub the universe data and identify any potential discrepancies systematically, thus saving time and resources for Sponsors.  

If you would like to explore how to efficiently and economically validate universe data, our compliance experts are eager to engage with you. Contact us today!