Successful UM-Focused Audits: ATTAC Supports Plan Preparation and Remediation
CMS UM-focused audits for Medicare Advantage are here.
As part of the 2024 Medicare Advantage and Part D Final Rule, CMS announced that utilization management (UM)-focused audits will be used to test plan and FDR compliance with new UM program guidelines. This rule defines the coverage criteria requirements for Medicare Advantage and Medicare prescription drug plans (Part D).
CMS will enforce UM program changes through routine and focused audits in 2024. CMS’s goal is to conduct enough audits in 2024 to ensure that 88% of Medicare Advantage enrollees’ plans are tested for compliance with the new rules.
ATTAC’s Clinical and Compliance Experts Will Help Your Plan Prepare for a UM-Focused Audit
We Also Provide Post-Audit Corrective Action and Remediation Support
Given the new, deeper scrutiny from CMS, plans can rely on ATTAC’s experienced clinical and compliance teams to:
- Test all CMS universes involved, including the new Table 7 related to termination of service for home health, skilled nursing, and comprehensive outpatient rehabilitation services
- Test application of UM criteria by reviewing a cross-section of denials and testing that they are consistent with national care decisions (NCDs) and local care decisions (LCDs)
- Review denial letters to ensure that they contain sufficient transparency about the reason for the denial and the criteria used; we’ll also provide feedback on how to meet CMS’s expectations.
- Test downstream delegates, such as IPAs or other UM delegates, to ensure they’re fully compliant with plan rules and criteria, and that their denial letters meet CMS requirements.
- Perform a UM-focused mock audit that mirrors CMS’s approach, including delegated entities, against final rule requirements.
- Help your plan review denial language and member communications to ensure compliance with CMS regulations.
- Review various criteria used by the plan’s UM committee, including ensuring that committees are well-structured and that coverage criteria are transparent and accessible.
- Prepare your plan’s medical directors and staff for stringent UM-focused audit requirements by collaborating with our senior clinical advisor, a physician expert in utilization management.
After the Audit: What if Our Plan Receives a Demand for Corrective Action From CMS?
ATTAC will help you develop an ongoing monitoring and oversight plan and assist with any necessary remediation post-audit.
If CMS requires your plan to submit a corrective action plan, ATTAC’s compliance and clinical experts will help build a step-by-step response. With decades of experience, our team is skilled at creating corrective action plans that are accepted by CMS.
