Trends in CMS Audits in 2023

Laura Ferrara, Chief Strategy Officer at Intus Care

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Over the last 10 months, Intus Care has participated in more than half a dozen Centers for Medicare and Medicaid Services (CMS) audits of PACE programs across the U.S. Beyond preparatory help for programs including mock audits, our Integrated Care Services (ICS) teams walks side-by-side with our partner PACE programs throughout the audit process, joining phone calls and meetings with CMS, helping with data and documentation, and offering advice for a successful audit process.

In this close journey with both new and renewing programs, we are seeing valuable insights into the key trends and findings on how the audit has changed this year over prior years. Here are some crucial takeaways.

Provision of Services

First and foremost, CMS is delivering on the 2023 audit protocols with an elevated scrutiny on provision of services and care coordination. Because assessments and care plans are where services start for participants, we saw more audit findings in this area. CMS was looking to see that the assessments were timely – not just every six months – but also if they changed with the participant’s status and condition.  

Building on the assessments, CMS is checking more critically on if the care plans reflected the needs of the assessment: do they contain all of the required elements? Is there evidence the participant received the services? And not only did they receive the services as expected, but was it effective in accomplishing what it was intended to do?  

In the past, the focus primarily has been around whether a service was ordered, authorized, and delivered. Now, we are seeing a much higher focus on the efficacy of the care being provided. If found to be ineffective, CMS wants to see that changes are being made to the care plan to be successful.

Care Coordination

We also saw increased scrutiny around care coordination, again, focusing on not just that it happened, but that it was also effective. CMS wants to see that the primary care physician is taking responsibility, ensuring interaction and teamwork with other physicians, hospitals, skilled nursing facilities, and specialist providers. CMS is looking more deeply past the provision of service to the impact of that service through the assessment, care planning, and care plan oversight process, ensuring they align with the interdisciplinary team's responsibilities.

In the next blog post, we will look at ways to navigate the intensity of the audit process, including what to expect and how to move forward for success in the future. In the meantime, contact Intus Care about mock audits through our website contact page:

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