The Centers for Medicare & Medicaid Services (CMS) released its annual Program Audit Update memo, outlining critical changes and updates for the 2025 program audits. Below are the key highlights and how Rebellis Group can assist your organization in navigating these changes:
Key Updates to the 2025 CMS Program Audits:
Audit Timeline:
CMS will send program audit engagement letters now starting in April through July 2025.
Audit fieldwork has been consolidated into two weeks:
Week 1: Operational program areas will be reviewed.
Week 2: Compliance Program Effectiveness (CPE) review will take place.
Root Cause and Impact Analysis Process:
Plans can now explain how the scope of identified noncompliance fits into their overall operations, allowing for a clearer understanding of the impact.
Focus on Part C Compliance:
CMS will continue assessing compliance with coverage and utilization management (UM)Â requirements finalized in CMS-4201-F.
This ensures Medicare Advantage beneficiaries can access medically necessary services without unnecessary burden or delays.
Suspensions of Data Collection:
CMS has suspended the collection of:
FA Table 3: Prescription Drug Event (PDE).
CDAG Table 7: Comprehensive Addiction and Recovery Act (CARA) At-Risk Determination (AR).
ODAG Table 6: Dual Special Needs Plan – Applicable Integrated Plan Reductions, Suspensions, and Terminations (AIP).
Independent Auditor (IA) Validation Requirements:
Sponsoring organizations will need to hire an independent auditor if more than 5 conditions unrelated to the CPE review must be tested during a validation audit.
If 5 or fewer conditions are identified, CMS will conduct the validation of all findings.
How Rebellis Group and our Family of Companies Can Help:
At Rebellis Group, we understand the complexities of CMS Program Audits and are here to support your organization every step of the way. Our expert services include:
IA Validation:Â Comprehensive validation services to ensure compliance with CMS audit requirements.
Universe Validation and Integrity Testing:Â Helping you identify and address potential issues within your data universes before submission.
Universe Scrubbing:Â Ensuring your universes are accurate, complete, and audit ready.
Audit Readiness and Support:Â Preparing your organization for CMS audits and assisting with root cause analysis and corrective action plans.
We also offer a subscription service that analyzes HPMS and regulatory memos, ensuring your team stays up to date with the latest information to support your success.
Whether your organization is preparing for a 2025 CMS Program Audit or finalizing work for 2025, our team at Rebellis Group is ready to help you achieve compliance, minimize risk, and streamline the audit process.
Let Rebellis Group partner with you to navigate these updates and drive better outcomes for your organization and your members.
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