CMS Audit Process Fails To Correct Problems With Medicare+Choice Plans, GAO Finds

The Centers for Medicare and Medicaid Services procedure for auditing Medicare+Choice plans "lack[s] a formal process" for "resolving" any issues the agency may find, a new report from the General Accounting Office found. Under the Balanced Budget Act of 1997, Medicare+Choice plans are required to file a report with CMS for "review and approval." These reports, called Adjusted Community Rate Proposals (ACRPs), outline the services a participating health plan intends to provide, estimate the cost of those services and estimate the reimbursement the health plan expects to receive from CMS. Under BBA, CMS is required to audit the ACRPs at least one-third of participating Medicare+Choice plans, while GAO is required to monitor CMS' audit process. To conduct its study of the CMS process, GAO interviewed "key" CMS officials and compared the agency's audit program against the requirements that MCOs must meet when submitting their ACRPS. In a review of 80 reports audited by CMS, GAO found that the audits were "not always complete or consistently prepared." Also, the GAO found that CMS does not have a "formal process" to address any problems its audits may find, effectively "limit[ing] the usefulness of the audits." Without a procedure to "follow up" the audit, problems and issues may "remain unresolved" and "undermine the utility" of CMS' auditing process. However, the GAO did find that CMS' audits "generally" meet BBA requirements (GAO report, "Medicare+Choice Audits: Lack of Audit Follow-up Limits Usefulness). The full report is available online.