2021 Outlook: As Audits ‘Return to Normal,’ MAOs Could Face Tougher CMS

The Trump years were noticeably light on Medicare Parts C and D program enforcement — and 2020 in general was a departure from normal operations — but as CMS resumes program audits and other oversight activities this year, Medicare compliance experts are advising plans to review key business functions. At the same time, industry observers say plans can expect increased enforcement and more aggressive use of civil monetary penalties (CMPs) in Parts C and D under the new Biden administration.

CMS last March suspended scheduled program audits of Medicare Advantage organizations, Part D sponsors, Medicare-Medicaid Plans and Programs of All-Inclusive Care for the Elderly to shift its oversight focus more directly on assuring the delivery of care during the COVID-19 pandemic (RMA 4/2/20, p. 1). The agency in July restarted program audits on a condensed basis and in a Dec. 23, 2020, memo said it expects to “conduct routine audit activities” for Parts C and D sponsors in 2021, sending audit engagement letters to selected organizations no earlier than mid-March and continuing to send them on a rolling basis through September.

© 2021 MMIT

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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