The 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) introduced new constraints on Utilization Management (UM) policies, particularly prior authorization, effective January 1, 2024. CMS aims to assess UM-related performance for plans covering 88% of beneficiaries this year through routine and focused audits. From client discussions, I have noted that these UM-focused audits show no sign of slowing down and have ranged from basic to quite extensive, emphasizing the need for thorough preparation.
CMS’s UM-Focused Audits and Goals
CMS-4201-F imposes stringent requirements on Medicare Advantage plans regarding UM policies. These audits are designed to ensure fair and equitable access to care by scrutinizing prior authorization processes to prevent unnecessary barriers. Since late February, CMS has increased audit activities, sending engagement letters and varying the scope of audits from basic checks to comprehensive reviews.
CMS’s objective is to evaluate the UM performance of plans serving the majority of beneficiaries through routine program audits and targeted “focused audits.” With CMS aiming to cover such a high percentage of beneficiaries, the likelihood of your plan being audited is substantial. These audits seek to identify and correct UM practices that may hinder patient access to necessary care, promote transparency and accountability within the Medicare Advantage program.
Four Critical Areas for Audit Preparation
To ensure compliance and readiness for UM-focused audits, Medicare health plans should concentrate on four critical areas:
1. UM Committee Composition
- Qualified Leadership: Ensure your UM committee is chaired by a medical director with the necessary qualifications and experience.
- Health Equity Expertise: Include at least one member with expertise in health equity to address disparities in care.
- Conflict of Interest Management: Establish clear processes for identifying, documenting, and managing conflicts of interest. Regularly review and clear conflicts, and implement protocols for handling recusals.
Key Questions:
- Is your UM committee chaired by a qualified medical director?
- Does the committee include a member with health equity expertise?
- How are conflicts of interest identified and managed within the committee?
2. Policy Review and Approval
- Comprehensive Review: Ensure that all UM policies, including those related to Part B drugs, are thoroughly reviewed and approved by the UM committee.
- Supplemental Benefits: Evaluate and approve supplemental benefits and criteria from First-Tier, Downstream, and Related Entities (FDRs).
Key Questions:
- Have all UM policies, including Part B drug policies, been reviewed and approved by the UM committee?
- Are supplemental benefits and criteria from FDRs reviewed and approved?
3. Health Equity Analysis
- Annual Review: Conduct an annual health equity analysis to assess the impact of prior authorization on enrollees with social risk factors.
- Public Accessibility: Make the results of this analysis publicly accessible on your plan’s website to ensure transparency.
Key Questions:
- Has the annual health equity analysis been conducted to assess the impact of prior authorization on enrollees with social risk factors?
- Are the results of this analysis publicly accessible on your plan’s website?
4. Transparency and Accessibility
- Public Posting: Ensure all internal coverage criteria and clinical guidelines are posted online in an easily accessible format.
- Timely Updates: Regularly update these criteria and ensure they include those from third-party entities.
Key Questions:
- Are all internal coverage criteria and clinical guidelines posted online in an easily accessible format?
- Are these criteria updated timely and include those of third-party entities?
Preparing for UM Audits: Practical Steps
- Regular Training and Updates: Conduct regular training sessions for your staff to ensure they are updated on the latest CMS requirements and internal UM policies.
- Internal Audits and Mock Reviews: Perform internal audits and mock reviews to identify potential areas of non-compliance and address them proactively.
- Documentation and Record-Keeping: Maintain thorough and organized documentation of all UM committee activities, policy reviews, and health equity analyses.
- Stakeholder Engagement: Engage with stakeholders, including patients, providers, and advocacy groups, to gather feedback and ensure your UM policies meet the needs of all beneficiaries.
Beyond the Audit: Sustainable Strategies for UM Excellence
Navigating the complexities of UM-focused audits under CMS-4201-F requires diligent preparation and ongoing compliance efforts. By focusing on the critical areas outlined above, Medicare Advantage plans can enhance their readiness for audits and demonstrate their commitment to providing equitable and efficient care.
HealthAxis’ strategic consulting services provide the expertise needed to ensure you are prepared for UM-focused audits and can assist with any necessary remediation. Our experts can help develop ongoing monitoring and oversight plans, ensuring your organization remains compliant. Schedule a call today to learn how we can support your success in the evolving healthcare landscape.
Author:
Milonda Mitchell
Compliance Officer
HealthAxis
