|
December 19, 2023
Breaking News: Medicare Advantage Utilization Management (UM) under scrutiny.
CMS expects to evaluate the UM-related performance of plans serving approximately 88% of people with Medicare Advantage.
On December 19, 2023 CMS released a memo titled 2024 Program Audit Updates. In this memo:
- CMS reconfirmed that the 2024 Program Audit season will begin in January 2024 and run through July 2024.
- CMS will conduct both routine and focused audits of organizations in 2024 to assess compliance with the coverage and UM requirements finalized in CMS-4201-F.
- Program Audits will include all previously applicable program areas, but will target the new UM requirements during the Part C Organization Determinations, Appeals, and Grievances (ODAG) review, as well as the Compliance Program Effectiveness (CPE) review.
- CMS is also adding new focused audits for plans who don’t have routine scheduled audits, which are limited to ODAG and CPE, and are designed specifically to target compliance with the coverage and UM policies in CMS-4201-F.
- Through this combination of routine and focused audits in 2024, CMS expects to evaluate the UM-related performance of plans serving approximately 88% of people with MA.
- CMS will also extend its Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) upon OMB approval.
- CMS will apply the 2022 MMP Audit Protocols and Data Requests to any audit that includes a Medicare-Medicaid Plan.
| 
