Upcoming CMS Prior Auth Audits—Are You Ready?
CMS has launched audits of the prior authorization processes for Medicare Advantage (MA) plans to evaluate their compliance with the new coverage and utilization management requirements (final rule CMS-4201-F) that went into effect January 1, 2024.
CMS is conducting regular program audits as well as focused audits specifically targeted to the new requirements, including Compliance Program Effectiveness (CPE) to ensure that plans are conducting adequate oversight of the processes. These audits, which are expected to cover 88 percent of MA enrollees, are already underway. This means that the vast majority of MA plans be audited for the new requirements in 2024.
Because the rule changes impact access to care—and because MA plan compliance with the new requirements are an area of particular interest to Congress—these audits are among CMS’s highest priorities in 2024. CMS has invested heavily in resources to conduct these audits, including physician reviewers for denied organization determinations (i.e., prior authorizations).
To ensure you are meeting CMS requirements and are adequately and appropriately documenting any organization determinations that were denials, it is strongly recommended that you conduct internal audits of processes involving the new requirements as soon as possible to allow time to correct deficient processes before receiving a CMS audit notice. CMS is taking these audits very seriously. You should too.
How we can help
Mock Audits
Toney Healthcare and our Rebellis Group colleagues offer a rigorous mock audit process to help you assess your compliance with these new requirements. We have extensive experience in health management including physician review, and deep knowledge of Medicare coverage criteria. Comprised of former CMS regulators and health plan operations and compliance executives, our team brings decades of experience conducting mock CMS audits (both from within CMS and as consultants) as well as CMS insider insight to its mock audit services.
We will bring this broad expertise to your business to evaluate your prior authorization processes in light of the new requirements, identify gaps, recommend corrective actions, and help you refine your processes to support compliance.
Audit Support
Our team is also available for onsite or remote audit support to ensure your CMS audit goes as smoothly as possible.
Experienced Utilization Management Resources
If your upcoming audit is diverting resources needed for medical or behavioral health utilization management operations, Toney Healthcare can fill the gap. We offer fast deployment of highly experienced utilization management, quality and compliance resources at all levels—leaders, nurses, medical directors, intake staff and more, all with relevant health plan experience, without the recruiting or hiring burden.
Ready to learn more?
If you would like to discuss how Toney Healthcare/Rebellis Group can assist with these activities, please contact us to discuss your needs, our capabilities and the audit process.
Additional Resources:
Roadmap for Navigating the 2024 Final Rule
