Photo of computer showing logo of CMS program audit

Annually, open enrollment activities are a true performance test of your company’s systems and processes. Challenges faced during open enrollment can lead to significant compliance risks for your organization as it enters the CMS 2023 Program Audit time of year.

CMS released their 2023 Audit Process Timeline on 11/30/2022 outlining the following 4 phases.

Phase I: Audit Engagement and Universe Submission

  • Engagement Letter
  • Universe Submission
  • Universe Integrity Testing
  • Audit Sample Selection

Phase II: Audit Field Work

  • Entrance Conference
  • Webinar Reviews
  • (Onsite) Audit of Compliance Program Effectiveness
  • Preliminary Draft Audit Report Issuance
  • Exit Conference

Phase III: Audit Reporting

  • Condition Classification and Audit Scoring
  • Notification of Immediate Corrective Action Required (ICAR) as applicableDraft Audit Report Issuance
  • Draft Audit Report Response
  • Final Audit Report Issuance

Phase IV: Audit Validations and Close Out

  • CAP Submission
  • CAP Review and Acceptance
  • Validation Audit
  • Audit Close Out

Here is the breakdown detail of each phase and CMS expectations.

The 2023 CMS Program Audit Process Overview document further outlines that CMS will send engagement letters to initiate routine audits beginning February 2023 through July 2023. However, engagement letters for ad hoc audits may be sent at any time throughout the year.

Program areas for the 2023 audits

Part D Coverage Determinations, Appeals, and Grievances (CDAG)

Compliance Program Effectiveness (CPE)

Part D Formulary and Benefit Administration (FA)

Medicare-Medicaid Plan Service Authorization Requests, Appeals, and Grievances (MMP-SARAG)

Medicare-Medicaid Plan Care Coordination (MMPCC)

Part C Organization Determinations, Appeals, and Grievances (ODAG)

CMS mock audits can identify any compliance risks within your current processes and systems. When conducting a mock audit you should prioritize:

  • Determining compliance risks to prevent future regulatory Corrective Action Plans (CAPs)
  • Identifying cross functional process improvements
  • Reviewing/developing audit universes
  • Preparing responses to audits and the requested documentation
  • Developing, executing and oversight of CAPs
  • Negotiating settlements as necessary

Outcomes your organization should expect include:

  • Reduced audit findings
  • Improved process controls allowing for smoother regulatory audits and reduced compliance costs
  • Continued alignment with CMS and state regulations
  • Increased CMS STAR ratings
  • Established effective and repeatable oversight tools
  • Strengthened oversight and accountability
  • Regulatory reporting readiness
  • Reduced risk of member and provider complaints, appeals, and grievances

Readying your CMS Program for audit is often challenged by budget constraints and other issues. A health care operations partner like Garnet Care has experience in this area and can offer a customized approach that delivers superior results with expert guidance and support.

To discuss your CMS Program audit readiness, email Courtney Seypura at or call Courtney at 518-605-0216.

Photo of Garnet Care practice lead Courtney Seypura

Courtney Seypura is practice lead for Garnet Care. She more than 20 years of experience in Medicare and Medicaid operations and project management. Garnet Care helps health plans, administrators, hospitals, and providers improve patient experience and program performance through system and process optimization.

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