Medicare Part D Readiness Review – Preparation and Compliance

Medicare Part D Readiness Review – Preparation and Compliance

  • 16 Dec 0
  • Share

Medicare Part D Readiness Review – Preparation and Compliance

Submitted by: Matt Zimmerman

The importance of developing and maintaining a Medicare Part D Compliance Program, focused on adhering to PACE guidelines, cannot be overemphasized. Plans that have a strong internal auditing and monitoring program in place are reassured they are within compliance regulations. 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.  Increasing numbers of PACE programs are reporting a growing trend in Part D audit intensity and complexity.

Why should PACE plans develop a Medicare Part D Audit preparation and compliance plan?

The Medicare Part D benefit is more than a ‘pass through’ payment program for prescription drugs. PACE plans are required by CMS to develop an effective Part D compliance strategy to focus on delivering all the necessary benefits of the Part D program.  Plans are required to do this in order to ensure their program is a good steward of Medicare program funds, avoiding all fraud, waste and abuse (FWA) of drugs as much as possible.  In consideration of these requirements, an organization must be committed to the development of a robust Medicare Part D compliance plan. The framework for this process is outlined in Chapter 9 of Medicare Prescription Drug Benefit manual (see link below). This chapter details the auditing and compliance requirements including the associated links to all the processes expected by CMS as they relate to the Medicare Part D benefit.

Solid audit preparation and compliance programs provide a vehicle to measure the success of any Part D program.

What are some ways to help develop a Part D Audit preparation and compliance plan?

  1. Establish a Part D committee. Directly involve key staff in the Medicare Part D program compliance efforts. This group should meet monthly to review all key aspects of the Part D program.
  2. Develop an internal tracking spreadsheet detailing key dates and program compliance audits.
  3. Schedule an independent 3rdparty review of your Part D program’s health. This method is generally conducted annually or as often as needed until internal program consistency is achieved.Typical FWA policies require plans to develop a series of routine audits to review key internal and external plan processes related to Part D. These results must be documented, tracked, maintained and reviewed for compliance initiatives and further development. This is accomplished through extensive development and review of procedure and documentation to support the overall Part D program.  Processes to review for an effective Part D compliance plan include: RAPS, PDE, Pharmacy Vendors, Prescription Delivery monitoring, prescribing patterns, grievances, and abuse monitoring by drug class.  It’s a good idea to regularly review routine processes such as: TrOOP, P2P, eligibility and Medicare & Medicaid payments.

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

While working with many clients, we have determined that Part D requirements are often poorly understood, the processes suffer from under-staffing and inadequate resources, and the data required for internal auditing and monitoring are difficult to obtain and analyze.   These difficulties are compounded when CMS issues modifications to the Part D program.  For these and other reasons, PACE organizations are at risk for non-compliance with Part D audits.

How we can help?

PACE Plans are required to have expansive policy and procedures supporting Part D compliance.  Capstone Performance Systems has both hands-on Part D experience and proven results in assisting PACE organizations in both preparing for and responding to Part D audits.   We have the expertise to examine your program’s Part D processes and identify gaps in compliance as well as methods to close those gaps.  Whether your program is preparing for an upcoming audit or working on corrective actions, we can assist.


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