Challenge

Many managed care organization lack experience in CMS Program Audits or have performed poorly in previously CMS Program Audits.  An MCO was preparing for an upcoming CMS audit and asked for our assistance.

Solution 

Excelsior Solutions has expertise in helping clients prepare for audits and participate in actual CMS Audits.

Client Win

We helped them prepare by coordinating a mock audit with the PBM.  This included:

• • • Developing the audit request notice
    • Identifying key areas for the audit
    • Selecting samples from the requested universes
    • Managing the deadlines and deliverables with the PBM audit team
    • Conducting the mock audit review of samples with the PBM and client in a similar manner to CMS Program Audits
    • Summarizing Immediate and Corrective Actions Required
    • Producing a final audit results summary
    • Working with client and PBM on remedial actions to correct deficiencies and implement best practices for improvements
    • Educating the MCO staff on how to answer auditor questions
    • Identifying deficiencies that needed to be reported to CMS in advance of the audit.  This resulted in reduced penalty and reduction of audit findings to observation