CMS Requirements for Monitoring and Auditing

CMS Requirements for Monitoring and Auditing

  • 13 Sep 0
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CMS Requirements for Monitoring and Auditing

Submitted by: Matt Zimmerman

The importance of developing and maintaining a robust Internal Monitoring and Auditing Program focused on adhering to PACE guidelines cannot be underestimated. Plans that have a strong program in place are assured in knowing that they are within the regulations and experiencing the reassurance that compliance adherence affords. Plans on the other side of the spectrum are plagued with the stress and worry that comes with either not knowing if they are compliant or outright non-compliance.

Why should PACE plans develop an Internal Auditing and monitoring plan?

First of all, an internal auditing and monitoring plan is a requirement for all Part D (i.e. PACE) plans by the Centers for Medicare & Medicaid Services (CMS). The guidelines for this process are outlined in Chapter 9 of Medicare Prescription Drug Benefit manual (see below). This chapter details the internal auditing and monitoring procedures and the associated links to other processes expected by CMS as they relate to the Medicare Part D benefit.

Plans that do not have a vigorous auditing and monitoring program are at risk of non-compliance with CMS regulations. Preparation for this requirement provides the ability to identify and respond to potential gaps in processing plus the added assurance that payments from CMS are in line with financial expectations.

Often times these responsibilities are outsourced to third party vendors. Solid monitoring and auditing guidelines provide a vehicle to audit the effectiveness and accuracy of First Tier Downstream and Related Entities (FDR). Auditing these entities provides additional confidence regarding the accuracy of outsourced processes.

What are some ways to develop an internal auditing and monitoring plan?

Some plans tie into this requirement through their Fraud Waste and Abuse Policy (FWA). Others may develop separate Auditing and Monitoring guidelines that stand alongside their overall compliance plan. Regardless of how this requirement is met, it is important to develop a series of routine audits to review key internal and external plan processes and functions. Results are documented, tracked, maintained and reviewed for compliance initiatives and further development. This is accomplished through extensive development of procedure and documentation to support the overall internal auditing & monitoring process. Internal audit processes include: RAPS, PDE, Pharmacy Vendors, Prescription Delivery monitoring. Examples of routine monitoring of Part D processes include: TrOOP, P2P, eligibility and Medicare & Medicaid payment indicators, including State and County Codes & institutional flags.

All results should be routinely reviewed internally by committee or department leaders to determine the best practices and standards for compliance.

How we can help?

PACE Plans are required to have expansive policy supporting this initiative and to personify the process as a leader in the PACE community. Take a moment and review your internal auditing and monitoring plans. Leading by example utilizing ‘data, information, knowledge and understanding’ is where we can help. Give us a call ~ we are always here to help you prepare for your next CMS audit.

Contact us for more information today.

Capstone Performance Systems | 720.204.2248 |  

Link to CMS Part D Chapter 9 – Compliance and program guidelines