Summary of the HPMS Memo Generated by USHER (Inovaare’s AI-powered Compliance Assistant)
The Centers for Medicare and Medicaid Services (CMS) issued a memorandum detailing several announcements relating to its 2024 CMS program audit. This includes new requirements for coverage criteria and the implementation of utilization management in the Medicare Advantage program (as per CMS-4201-F). CMS plans both routine and focused audits for 2024 to verify compliance with these new regulations. A notable feature in these audits will be the use of physician reviewers to assess compliance with the new clinical coverage requirements. Also, preparations are underway for the extension of Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717).
Further, details related to the revised audit processes, requirements, and timetable were provided, prompting organizations to review the changes, prepare accordingly, and utilize available resources to aid in their preparations for the 2024 CMS program audits.
Actionable Items:
- Review new requirements regarding coverage criteria and utilization management (UM) requirements implemented in CMS-4201-F and prepare for potential audits related to this.
- Prepare for both routine and focused audits to be conducted in 2024 by CMS.
- Based on the “2024 Oversight Activities” HPMS memo, anticipate additional focused audits for organizations without routine scheduled audits.
- Prepare for physician reviewers’ assessment of new clinical coverage requirements during audits.
- Await the forthcoming Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717).
- Note the schedule for receiving CMS’ program audit engagement letters, which will begin in January and run through July 2024.
- Review the changes applicable to 2024 program audits, including application of the 2022 MMP Audit Protocols and Data Requests to any audits that include Medicare-Medicaid Plan, suspension of PDE, CARA, AIP Universe collection, and requirements for hiring an independent auditor under certain conditions.
- Make use of resources available on the (https://www.cms.gov/medicare/audits-compliance/part-c-d/program-audits) to prepare for 2024 program audits.
- For questions relating to the audit process, send emails to [part_c_part_d_audit@cms.hhs.gov](mailto:part_c_part_d_audit@cms.hhs.gov).