CMS’ Medicare Advantage (MA) program audits are getting tougher and more detailed every year.
About The Podcast:
Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.
Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.
Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.
Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.
Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.
Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.
About The Episode:
On this episode, Marc discusses Medicare Advantage compliance. CMS’ program audits are getting tougher and more detailed every year.
Key Takeaways:
Overall, CMS’ program audit protocols are fair and reasonable. They hold plans accountable for the delivery of care to Medicare beneficiaries.
There are four core audit protocols and a fifth for Special Needs Plans.
The 2023 and 2024 program audit report shows MA audits are getting tougher and more detailed.
Compliance Program Effectiveness is closely being scrutinized due to concerns about oversight of delegated vendors.
Formulary Administration is also an active area due to concerns on correct prior auth edits, claims configuration, cost-sharing, and transition fills.
Scrutiny of medical service and drug authorizations and appeals remain very detailed, with clinicians digging deep into cases and determination of medical necessity.
On Special Needs Plans, CMS is always concerned about health risk assessments but is now going beyond that to determining if care plans are addressing all of the identified needs of individuals.
CMS says plans are implementing and carrying out the new utilization management rules, but scrutiny should increase in the future.
Financial audits are also increasingly rigorous and focused on no beneficiary harm.
Record civil monetary penalties were levied in 2024.
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Resources:
The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
