Top 6 Questions Asked During a CMS Independent Audit Validation

Understand the scope and specific issues and what to expect in the process

CMS has begun enforcing changes to Medicare Advantage and Prescription Drug Benefit programs and recently released their 2017 audit notices for Health Plans. A validation audit, or independent audit (IA), is much different than a full program audit. Knowing the differences is crucial to a successful validation, and understanding the scope and specific issues are critical to navigating the validation process and getting back to business. Since the process can be complex, we have answered commonly asked questions by sponsors.


Question 1: How long does the validation process take?

Navigant: This depends on when your CAPs are approved by CMS and your clean period determination, so times may vary. Navigant utilizes a phased approach and a methodology that has proven to keep validations on track and within scope. We work collaboratively with plan sponsors during each phase of a validation audit to ensure all expectations and outcomes are thoroughly communicated. After the clean period is complete, the time from validation to final CMS report is approximately six to eight weeks.

Question 2: What documents do you request and what does the document review entail?

Navigant: Any documents you refer to in your CMS approved CAPs will be requested as evidence that they were completed for recording purposes only. For instance, if a CAP refers to a new or updated policy and procedure, that document will be requested and noted in our report as having been received. We do not audit the documents themselves for correctness.

Question 3: Do you validate the observations that CMS identified in our final audit report?

Navigant: No. CMS has indicated that only CARs and ICARs will be validated according to your CMS approved CAPs.

Question 4: Can you stagger the testing and the clean period?

Navigant: Yes. Plan sponsors have to decide whether to wait for all areas to be remediated or to indicate that some areas such as Part D are “clean,” while others will not be until a later date. The IA would then conduct a phased or staggered approach provided that this is amenable to CMS.

Question 5: What is the overall role of the IA?

Navigant: The IA is to perform the audit using the CMS audit protocols and its own skills and experience to provide the information to CMS and the plan, which documents whether the issues that gave rise to the conditions are corrected and not likely to recur.

Question 6: Does the IA issue a “pass or fail” type of opinion or determination?

Navigant: No, that is for CMS to determine. The IA gathers and tests the facts and presents them in a manner that is easily understood. Only CMS has the authority to deem the audit and its conditions closed or to release a plan from sanctions.

About the Experts

Back to top