Medicare Advantage Auditing: Are You Prepared?

The Center for Medicare & Medicaid Services is a federal health and human service agency that administers major state healthcare programs in the United States. 

Ever wondered how CMS (Center of Medicare & Medicaid Services) keeps an eye on how well health plans deliver care to Medicare beneficiaries? Its best tool is a program audit. A CMS program audit failure can cause lifetime financial penalties and even an enrollment freeze. 

CMS urges all medical entities to perform internal Medicare Advantage mock audits as a part of ongoing payment integrity protocols. Medical facilities should take it seriously and act now to identify any potential problems inside the organization before CMS does and take reliable actions to fix them.  

CMS Audit area of focus

CMS conducts Medicare Advantage auditing to measure a health plan's compliance with federal and state regulations, including the accuracy of providers. CMS evaluates the performance of a healthcare organization in the following areas:

    • Member eligibility

    • Financial Reporting

    • Service authorization request

    • Data submitting

    • Appeal & Grievances

    • Provider payment request

CMS collects and analyzes data, releases findings in a report, and works to eliminate abuse and fraud within the state’s healthcare system. 

How to be ready for the Medicare Advantage auditing?

One of the best ways to be prepared for CMS auditing is by executing a Medicare Advantage mock audit before the real CMS audit team enters your facility. The resulting mock audit report will contain information regarding the weak points of your facility. 

You can use this information to take necessary measures to fix the potential issues before the CMS identifies them and applies penalties to your organization. 

How to conduct a Medicare Advantage mock audit?

Professional medicare consultants can help you conduct  Medicare Advantage mock audits in your facility. They can replicate a CMS audit to evaluate your team's performance and accuracy of the medical procedures in various departments in your facility. 

They will train your team on what to expect during an actual Medicare Advantage auditing process and provide coaching on how to respond to CMS interview questions. In the end, you can rest assured that they will equip your team with the necessary steps to improve your compliance and successfully pass an audit. 

Experts will assist your team during the audit so they can focus their entire attention on CMS  requests and questions. They will help create and review the universe and prepare documentation. So calling the experts is definitely a worthwhile decision.