CMS seems to be taking its own advice when it comes to continuous quality improvement — at least in the program audits of Medicare Advantage plans. As outlined by agency speakers at the CMS MA and Part D spring conference May 6, there has been an overhaul of the methodology used in the audits starting this year in order to put the emphasis on finding the most serious problems and dealing with them severely. But budget limitations could limit how many audits the agency can do with the new methodology.
The new approach for 2013 was described by several CMS speakers led by Jonathan Blanar, deputy director of the Division of Audit Operations in the Medicare Parts C&D Oversight and Enforcement Group (MOEG). It includes, he explained, focusing “on the number and severity of unique conditions identified” in the audit rather than continuing the approach used in 2012 of determining failure based simply on assigning pass or fail grades to each plan area examined without differentiating the significance of the failures.
Instead of that, this year CMS auditors will score failures based on how pervasive the problem is, how important it is and whether the failure is the result of a systemic weakness in the health plan rather than a single human error unlikely to recur. The plan’s audit score will depend on the number of conditions identified in the final audit report, the degree of “remediation” required for each condition and the number of audit elements tested. CMS plans to do 29 audits this way in 2013 — if it has the money — and to give details about the results on the MOEG website.
What do you think about the new approach? Will it make a difference in how MA organizations prepare for audits and react to findings? In a year of very limited resources for government agencies, will the new approach work as planned? And regardless of that, should CMS get kudos for practicing what it has preached about transparency since the days of former Administrator Don Berwick, M.D.?
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