How to prepare for a CMS audit

CMS audits assess Medicare plan sponsors’ compliance with a number of core program requirements, chief among them is the plan’s ability to provide its members with access to medically necessary services and prescription drugs. Audit scores and enforcement actions resulting from these evaluations are published by CMS and can have major implications for a plan’s future and enrollment. Poor performance could result in a plan facing fines, marketing, and enrollment restrictions, or even termination of CMS contract.

An audit engagement can be received at any time and, once a plan has received notification from CMS, an audit will progress quickly and in accordance with established protocols. Ideally, a detailed work plan has already been defined and documented—but plans and PBMs shouldn’t wait for an audit engagement to prepare.

Here are some ways Abarca helps its clients and partners stay ready for an audit:

  • Prepare monthly universes. Abarca pulls universes on a monthly basis and treats the data as if it were a real CMS audit—including performing comprehensive validations to ensure the integrity of the data and compliance with technical specifications. This also gives us the opportunity to identify and address any issues ahead of an audit and allows visibility that we may not have otherwise had due to time constraints. Additionally, having these monthly universes readily available also helps us move quickly to meet submission requirements.
  • Encourage self-disclosure. Abarca’s client relationships are built on two pillars: maintaining open communication and transparency. With our issue management strategy process, we ensure that any non-compliance issue is identified and corrected and that the preventive mechanisms are timely and well documented, allowing plans to conduct a self-disclosure to CMS at any time. When the time comes for an audit, if the plan has been able to demonstrate that these issues were promptly identified and corrected and that any potential risk to enrollees has been mitigated, they may not be factored into the plan’s score.
  • Get the team in place. Successfully navigating a CMS audit requires a strong and collaborative team. Abarca has policies and procedures in place defining audit processes and responsibilities. Immediately upon receiving an audit notification, an internal kickoff meeting takes place so we can make sure that everyone is prepared for their role. In the event that someone is unable to fulfill their duties during the audit, we also have backup team members ready to jump in.</li
  • Perform mock audits and internal dry runs. Abarca regularly performs mock audits and internal dry runs to evaluate data and validate our responses to any issues that may arise. This not only helps us prepare for and accommodate CMS’s quick turnaround times for unplanned or on-the-spot requests but ensures that our team is ready and confident within their roles. It also reduces the risk of surprises during the case discussions with CMS and during the audit.
  • Utilize modern technology. There are a number of processes that health plans perform manually, which can leave room for errors. Without the right technology in place, these inaccuracies may go unnoticed until an audit is underway. Abarca uses Darwin to generate automatic universes and reports, and flag potential discrepancies, so that any issue can be more easily identified and managed promptly.

Looking ahead
The CMS requirements and regulatory landscape for Medicare Part D are continuously changing. And during the onset of the COVID-19 pandemic, CMS has allowed for certain flexibilities and waivers to facilitate better access to care with less burden for beneficiaries. However, considering the tremendous amount of funds invested by the federal government during this national Public Health Emergency declaration, plan sponsors should reinforce internal monitoring and auditing efforts, and expect a possible increase in auditor scrutiny during the next Program Audits.

At Abarca, we don’t believe in leaving anything to chance. With careful preparation and a collaborative and transparent working relationship, we will continue supporting our clients and helping them achieve the best audit scores possible.


This blog was written by Angeles Monroig Bosque, JD, CHC, Compliance Officer at Abarca.


Be part of the future of healthcare

We are on a mission to transform the prescription experience and enable a broader healthcare revolution. Join us!

Contact Us