2024 Program Audits
Review the final rule CMS-4201-F, 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) | CMS, issued by CMS April 5, 2023. The following Enhancements to Medicare Advantage and Medicare Part D would apply to coverage beginning on 1/1/2024:
- Ensuring Timely Access to Care: Utilization Management Requirements
- Benefit criteria for prior authorization use
- New continuity of care requirements
- Annual review of all UM tools
- Protecting Beneficiaries: Marketing Requirements
- Strengthening Quality: Star Ratings Program
- Advancing Health Equity
- Improving Access to Behavioral Health
- Provisions were made to the following Acts:
- Bipartisan Budget Act of 2018
- Consolidated Appropriations Act (CAA) 2021
- Inflation Reduction Act (IRA) of 2022
CMS Oversight Activities were announced back on October 24, 2023, with their routine and focused audits to assess compliance with the coverage and UM requirements finalized in CMS-4201-F.
2024 Program Protocols
CMS will use the OMB-approved version of CMS-10717 to conduct its 2024 program audits and program audit engagement letters will be sent out January through July 2024.
Additional Information on the 2024 Program Audits
2024 Program Audits will:
- Apply the 2022 MMP Audit Protocols and Data Requests to any Medicare-Medicaid Plan (MMP) audit
- Suspend collection of 3 universes:
- Table 3: Prescription Drug Event (PDE)
- Table 7: Comprehensive Addiction and Recovery Act (CARA) At-Risk Determination
- Table 6: Dual Special Needs Plan – Applicable Integrated Plan Reductions, Suspensions, and Terminations (AIP)
- Require the hiring of an independent auditor when there are more than 5 conditions unrelated to the CPE review that must be tested during the validation audit
Program Audit Resources
The following resources are available to help prepare for 2024 program audits.
- User Group Resource Document
- FA Validation Work Plan Training for Medicare Advantage and Prescription Drug Plans
- Program Audit Process Overview Document
Challenges faced during open enrollment can lead to significant compliance risks. As you enter the CMS 2024 Program Audit time of year, let Garnet River Healthcare perform a CMS Mock Audit to identify any compliance risks within your current processes and systems. Mock Audits and Audit support we can provide:
- Determine compliance risks to prevent future regulatory corrective action plans (CAPs)
- Identify cross functional process improvements
- Review/develop audit universes
- Prepare responses to audits and the requested documentation
- Develop, execute and oversee corrective action plans (CAPs)
- Established effective and repeatable audit oversight tools
Garnet River Healthcare also understands budget constraints and ongoing challenges, which is why we’re committed to doing more with less. Our customized approach delivers superior results with expert guidance and support.
Let’s talk! Contact me at cseypura@garnetriver.com or give me a call at 518-605-0216.
Courtney Seypura is practice lead for Garnet River Healthcare. She has more than 20 years of experience in Medicare and Medicaid operations and project management. Garnet River Healthcare helps health plans, administrators, hospitals, and providers improve patient experience and program performance through system and process optimization. Courtney can be reached at cseypura@garnetriver.com or 518-605-0216.
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