Partnering to Help a Health Plan Complete CMS Audits

Change Healthcare Consulting helped a midsize plan that failed CMS revalidation audits of its Medicare line of business. To meet CMS regulatory requirements and pass revalidation audits of the plan’s Medicare line of business, Change Healthcare Consulting helped reconfigure the plan’s utilization management system with real-time testing, trained staff, better workflows, and automated reporting. The health plan now automatically populates CMS universes for weekly monitoring and better data integrity. The payer also passed a timeliness revalidation audit with 100% and a data validation audit with no findings.


A midsize Medicare health plan


A midsize health plan was unable to meet mandated regulatory turnaround times to track utilization management (UM) decisions. The previous medical managements system was antiquated and the health plan struggled with high staff turnover. Moreover, the plan had failed two successive CMS timeliness revalidation audits.


Population Health Consulting Services


The plan upgraded its care management system and now automates data input. Staffing is stable. The health plan passed timeliness revalidation audit with 100% of cases meeting turnaround time requirements and passed CMS data validation audit with no findings.

Change Healthcare Consulting helps health plans improve care management systems to help meet CMS requirements. Normally, the process takes six months; we resolved one midsize plan’s challenges in three.

The risk of failing CMS audits

One of the biggest business risks for a health plan with Medicare products is to fail a Centers for Medicare & Medicaid Services (CMS) audit. Prior to 2020, the midsize plan found itself unable to meet mandated regulatory turnaround times to track UM decisions having failed two successive revalidation audits. Last year, the health plan turned to Change Healthcare Consulting to help improve business workflows to meet CMS requirements. This normally takes at least six months. With help from the client and its care management system vendor, Change Healthcare Consulting resolved the issue in three months.

Outlining problems with the care management system and low staff morale

There were three core problems that Change Healthcare Consulting found:

  1. The care management system was outdated.
  2. The system’s configuration wasn’t documented.
  3. There was a demoralized employee base and high staff turnover.

The Change Healthcare Consulting group created an improvement plan to help the plan with:

  • Clear, defined goals.
  • Documented CMS business requirements.
  • A new team that made the project a top priority.
  • Upgraded and reconfigured UM portal and updating processes.
  • New CMS EOD (14-day) and SOD (24- or 72-hour) member care determination monitoring and auditing reports.
  • Meetings to support staff and obtain feedback, access changes, and answer questions.
  • Daily meetings with the UM vendor on system changes and reporting.
  • New and updated policies, procedures, and training materials.

Outlining the role and goals of modernization and automation

When it came to the medical management system itself, Change Healthcare Consulting helped:

  • Modernize the software.
  • Understand and implement configuration requirements.
  • Automate what was a largely manual data input process leading to poor data quality.

The care management system was poorly maintained, and the health plan wasn’t using all available functions. To help improve the process, Change Healthcare Consulting reverse-engineered the software to understand which fields did—or did not—map to CMS universe requirements.

The Change Healthcare Consulting team then helped the payer automate data input with well documented processes.

The importance of testing the system

Change Healthcare Consulting and the plan worked with the care management vendor to install and test a new system upgrade to help build reports and configure fields.

Initially the client didn’t have the right set of resources to upgrade its medical management system. Change Healthcare Consulting helped establish and train a team to focus on compliance and improve vendor coordination. That team included the compliance staff, the healthcare IT team, the medical director, and executive leadership.

The cultural factor: the key roles for training and communication

Training was key. Change Healthcare Consulting supplied a CMS compliance subject-matter expert, a trainer, and a manager. The result: As processes and workflows became more efficient, morale increased and staff turnaround decreased.

To establish regular, consistent communication, Change Healthcare Consulting hosted weekly meetings where participants had clearly defined roles. (During the refresh and field mapping, process meetings were as frequent as three times weekly.)

That helped the team track and follow up on action items discovered in meetings and share corrective action plans with compliance and executive leadership. There was a new process to test and train prior to the system upgrade.

Change Healthcare Consulting helped eliminate a “finger pointing” blame game between the plan and the vendor, leading to better quality testing and new documentation.

When a modernization program leads to faster business processes

Apart from accuracy, the other outcome was speed. Improved vendor-plan coordination meant that issues usually were addressed in one business day. And, because of the push to automate, regulatory reports were run quickly and accurately with little to no manual intervention.

Now, the plan uses CMS regulatory reports to support daily monitoring meetings and quickly identify the need for corrective actions. Some lessons learned, which apply to any plan:

  • Test with real data.
  • Identify key players and align expertise.
  • Establish continuous monitoring and audits.
  • Develop concise corrective action plans with realistic completion dates.
  • Work to triage workload based on level of risk.
  • Make compliance and regulatory risk top priorities.
  • Build collaboration with your vendor partners.
  • Get support from executive leadership.
  • Ask for feedback from staff on ways to make improvements.

While requirements are different, the same approach to collaboration, automation, and accuracy also can be applied to Medicaid, the Health Insurance Marketplace® exchange, and commercial lines of business.

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