Areas of Focus on Recent CMS 1/3 Financial Audits

The 1/3 Part D Financial Audits constantly change as CMS directs its auditors to focus on different areas of compliance risk for PACE organizations. Here are some of the specific areas of interest we have observed auditors verifying in CY 2018 and 2019 audits:

  • Part D, Financial, and FWA policies and procedures (P&Ps) are in place and internally audited and monitored regularly; corrective action plans (CAs) have been created and acted upon for any process anomalies identified.
  • Vendors, providers, and employees regularly are screened against the Preclusion List, Office of the Inspector General (OIG) Exclusion List, General Services Administration (GSA) List (optional), and Outlier Provider/Prescriber Report.
  • Professional licenses and certifications are verified upon hire or contracting and annually thereafter.
  • Prescriptions are linked to an appropriate (FDA approved) diagnosis code.
  • Prescriptions for non-FDA approved diagnoses are not submitted as PDE; PACE may provide these drugs, however they are not Part D.

If you realize your plan is out of compliance or your policies and procedures are out of date in any of these areas, you should start working to correct the deficiencies as soon as possible. If your plan is selected for audit on the next round, it is good practice to disclose the areas of non-compliance you found and provide the status of your CAP. It is better to disclose this information and show the auditors that you are working to correct the deficiency than to let the auditors find the problem and create a finding on your audit report.

In the next issue of Pharmastar News, we will look at a few additional areas on which auditors have been focusing attention.