CMS Audit Preparation for Provider Data Accuracy and Compliance

For health plans, a CMS program audit failure can trigger financial penalties, sanctions and even enrollment freezes. PRIME’s CMS mock audit services assist Health Plans with preparing to respond to a CMS provider directory audit successfully.

CMS Audit servicesThe Centers for Medicare and Medicaid Services (CMS) is a federal Health and Human Services agency that administers major federal and state health care programs in the U.S. In addition to Medicare and Medicaid, it also oversees the Children’s Health Insurance Program and state and federal health insurance marketplaces.

As part of its mandate, CMS collects and analyzes data, releases research reports, and works to eliminate fraud and abuse within the nation’s health care systems. It also conducts various audit programs designed to measure a health plan’s compliance with the state and federal regulations, including provider directory accuracy.

All health plans with providers that treat Medicare and Medicaid patients are subject to CMS auditing. Complying with CMS regulations is challenging for Health Plans and a CMS audit is almost a certainty these days. One way to ensure a successful audit is by performing mock audits based on the same criteria official auditors use.

Be Ready for CMS Audits with Mock Audit Preparation

PRIME assists Health Plans in preparing for an audit by executing a mock audit as if it was performed by CMS. The resulting report contains information that the plans can use to help them identify issues and suggest actionable tasks to remediate them before the actual CMS audit identifies them.

PRIME has in-depth audit capabilities intended to ensure outreach compliance:

  • All event workflows including outreach attempts are cataloged
  • All outreach artifacts such as telephone recordings are stored for reference
  • All interactions including data field modification are preserved

Provider Data Accuracy and PRIME’s Validation Model

CMS requires a Health Plan to monitor and conduct regular updates of its provider network data, including office information and any other changes that affect availability. Because CMS audit reviews consistently show high rates of inaccuracies in provider directories, the agency now requires plans to update their online directories in real-time every three months.

Without creative solutions that can improve provider directories with minimal burden, guaranteeing accuracy will continue to be a problem for Health Plans. If you want your provider data to remain compliant so as to avoid substantial fines, traditional data validation methods are no longer enough.

PRIME’s direct outreach uses emails, letters, fax, phone, and provider-convenient channels to simplify the validation process. We also track which provider records need to be updated and coordinate directly with a plan’s administrators. Our dashboard reporting provides real-time insight into trends and overall outreach status.

If you want to ensure that your provider data is accurate, complete, and timely, contact us today to discover how PRIME’s CMS audit solutions can add business value and boost your bottom line.