Creating the required universes for CMS Program Audit submission remains one of the most arduous and time-consuming tasks for MAPD and PDP plans. Health plans often struggle to complete this critical step and ensure their universes are clean and error-free.
If you underwent a CMS program audit in 2015 or 2016, you experienced the rigorous timeliness review of your Part C Organization Determinations, Appeals and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG) universes. CMS designed this review to validate universe accuracy and measure timeliness across each audit area.
CMS Update
Now, all MAPD and PDP plans must undergo reviews, whether or not CMS selects them for an audit this year. In November 2016, CMS announced an industry-wide timeliness monitoring activity for Part C organization determinations and appeals and Part D coverage determinations and appeals.
This initiative serves two main purposes: first, to evaluate the integrity and completeness of the Independent Review Entity (IRE) data, and second, to enhance compliance monitoring.
Since January 2017, CMS has been collecting seven ODAG universes and ten CDAG universes from each contract to assess timeliness in processing both Part C and D requests and ensure proper case forwarding to the IRE. CMS defines an acceptable universe based on field type, length, description, and date field calculations.
Plans can attempt a maximum of three submissions to provide accurate and timely universes during a CMS audit. If they fail, CMS may classify the submission as an Invalid Data Submission (IDS) condition for each audit element that lacks sufficient test data or grouping by case type. This failure can lower STAR ratings and audit scores. Moreover, plans that fail to submit universes successfully risk facing compliance actions from CMS.
Program Audit Universes as a Powerful Compliance Tool
To help mitigate risks associated with inaccurate or untimely audit universes, we enable plans to create clean, accurate, and CMS-ready program audit universes. These universes not only support CMS audits but also serve as valuable tools for ongoing compliance monitoring. By reviewing universes regularly, plans can assess operational performance, identify potential issues proactively, and resolve them in advance.
Key Questions to Consider
- Are you generating clean universes for CMS submission?
- What is your error rate?
- How many man-hours do you spend fixing errors?
- Are you leveraging your universes as an ongoing monitoring tool?
- Are you experiencing penalties and delays?
To learn more about our solution for generating clean audit universes, please visit Universe Scrubber.