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A health plan client had become concerned about their ability to pass a possible CMS Medicare audit unscathed. An externally-sourced mock audit revealed some shortcomings, but was limited in its comprehensiveness due to the plan’s inability to produce a full set of the customary data that the auditor could access and analyze (audit universes).

Starting from the findings of the mock audit, and using the published CMS audit approach as a framework, SDLC guided the client and its service partners toward a better view of the processes and systems that needed to be improved.

Beyond the new degree of audit preparedness, the data analysis work created better oversight and performance evaluation across the business continuum — from their own department and across all of their third party service partners.

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The Challenge

A health plan cannot fully prepare for a mock audit if they don’t have adequate and deep access to critical data for review and analysis. That was the challenge faced by a health plan client who hired an auditor and received results limited by the lack of timely prepared audit data.

This payer uses several third party service providers for a variety of Medicare benefit areas — front and back office delivery of claims management, member management, as well as appeal and grievance processing. The number of integrated first-tier parties, the lack of automated data integration for auditable “soft data” (i.e. customer grievance notes) and the newly changed guidance by CMS, resulted in a situation where there was no thorough and reliable way to ensure full compliance oversight. This created a sizable audit risk.

The implications of a CMS audit are well known and very real — ranging from corrective action plans and possible fines to curtailing enrollment and shutting down a plan’s Medicare products.

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The Solution

Employing SDLC Partners’ Execution Model, we first conducted the discovery and root cause phases. Discovery included a review of the audit findings along with a full documentation of their current state processes. Next, we reviewed all processes and systems for root causes of the documented shortcomings and for potential, future failure points. These issues were subjected to a risk assessment. Jointly with the client, we developed options and recommendations for targeted resolutions to these issues.

In the end, there were hundreds of recommendations, ranging from small process improvements to developing new business and technical solutions. We helped the client prioritize and focus on those most important to compliance, as well as their affect on member health and the plan’s financial health. A proprietary SDLC decision tool aided the prioritization step. Finally, a roadmap was developed jointly to guide their strategic next steps.

In a subsequent step, SDLC designed and implemented a business intelligence solution that combined audit data from all internal and external sources into a unified data model, the CMS Audit Data Mart. The data mart would not only provide comprehensive ODAG audit universes, but  also drives newly developed key performance indicator reports and trend analyses across the entire business continuum for the client’s Medicare Line of Business.

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The Result

Before this opportunity, the payer didn’t have all of the necessary information in one location and available in a format that allowed audit prep, response, and analysis to be done in a timely manner. By creating a data unaversive view, they can populate dashboards automatically and provide unparalleled oversight of those third party vendors so critical to their CMS compliance efforts.

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