Creating Your Audit Playbook as a Medicare Advantage Health Plan

June 26, 2020 – ZeOmega

Each year, a percentage of randomly selected Medicare Advantage health plans face a detailed audit from the Centers for Medicare and Medicaid Services (CMS). The audit is designed to ensure compliance with stringent regulations and consumer safeguards.

While COVID-19 has led CMS to provide additional flexibilities in 2020 to prevent undue hardship on MA plans, the usual audit process requires plans to submit a long list of reports and documentation illustrating compliance with time-sensitive actions, clinical decision guidelines, and member communications.

The results of these audits are public and can have significant impacts on member enrollment decisions – not to mention wide-ranging financial and operational implications for the plans themselves. Audit results can influence an MA plan’s Star Ratings, rebate percentages, risk adjustment calculations, and marketing permissions, all of which can dramatically affect a plan’s ability to thrive in a very crowded marketplace.

Fortunately for health plans, most of the audit requirements are not a surprise. MA plans receive a preview packet with a submission checklist before the review takes place, allowing administrators to prepare in advance for the lengthy process.

Nevertheless, some health plans still struggle to pull together the right data in a comprehensive, manageable way. Plans that lack automated processes, integrated visibility into their data, and a coordinated approach to regular self-assessment may be less likely to succeed when an audit comes around.

As we continue our blog series on the top challenges in Medicare Advantage, we’ll discuss the need for health plans to develop their own audit “playbook” that helps to identify opportunities for improvement in compliance processes, member services, and administrative efficiencies long before CMS sends an audit notification.

Building a data-driven environment for audit success

Medicare Advantage audits aren’t something health plans can cram for at the last minute. These detailed assessments of a plan’s operations are designed to ensure that compliance is happening every single day. A unified, streamlined data management platform is key for laying the foundation for success with all of a health plan’s responsibilities.

As we discussed in our previous blog post on compliance, MA plans that rely on disparate data management systems or manual processes may be at a disadvantage when it comes to meeting regulatory benchmarks. With many decision-making and notification tasks timed down to the second, health plans simply cannot afford not to have full visibility into every transaction that takes place.

An integrated and highly automated data-driven environment is essential for identifying opportunities to improve workflows or speed up communications. With the right digital platform, MA plans can even pinpoint the root causes of bottlenecks with extraordinary precision, such as a glitchy fax machine or a staff member who may need retraining on how to complete a report. Fine-tuning these processes before an audit takes place is the best way to prepare for a positive outcome.

Developing the step-by-step audit playbook

With enhanced visibility into compliance processes and the ability to analyze and manage transactions at a detailed level, health plans can begin to create their audit playbook. The playbook is a comprehensive rundown of how every determination and activity maps directly to internal plan policies and Medicare Advantage compliance regulations. This roadmap allows auditors to understand exactly how automated processes function and how decisions are being made.

The playbook should include all methodologies related to pulling data into the reports required by auditors. It should also include current, complete digital copies of all the administrative policies and procedures related to important decisions. This allows health plans and regulators to ensure that the right data is being compiled and used to determine compliance – something that may be surprisingly difficult to get right in some situations, especially when time-sensitive information is relayed through multiple checkpoints that each generate unique timestamps.

The ability to trace every data element through every touchpoint is essential for demonstrating that a health plan is remaining compliant with all relevant rules and regulations. Maintaining an organized, comprehensive playbook of these pathways, policies, and decision trees can eliminate confusion, help identify necessary improvements, and ensure a smooth and successful audit.

Fostering continuous improvement with mock audits

The audit playbook should get plenty of exercise during regularly scheduled internal mock audits. Mock audits help health plans ensure that a culture of compliance is deeply embedded in their workflows and decision making. By maintaining visibility into administrative processes, member relationships, and clinical decisions, MA plans can continue to deliver the highest possible level of service to consumers while staying prepared for CMS assessments.

While the CMS audit process can be lengthy, conducting a mock audit doesn’t have to be arduous and time consuming. An up-to-date and comprehensive playbook can significantly simplify the task of moving through the audit checklist. And health plans that adopt the right robust data management tools may have access to “one click” auditing features that run all the necessary reports without the need for extensive manual involvement.

Without the need for staff members to commit too many additional hours to conducting mock audits, health plans can continue to operate efficiently and make necessary improvements while still being confident in their readiness for a real CMS review.

Coming up next

In our next blog post, we will dive into the importance of addressing the social determinants of health as part of a holistic, person-centered approach to member services. We will explore how innovative data analytics tools and member relationship strategies can help MA plans design new benefits, improve outcomes, and control costs for high-needs populations.