Medicare Advantage mock audits are a type of assessment tool used by Medicare Advantage organizations (MAOs) to prepare for actual government audits and ensure compliance with Medicare Advantage regulations.
The Center for Medicare & Medicaid Services is a federal health and human service agency that administers major state healthcare programs in the United States. CMS urges all medical entities to perform internal Medicare Advantage mock audits as a part of ongoing payment integrity protocols.
Medical facilities should take it seriously and act now to identify any potential problems inside the organization before CMS does and take strict actions to fix them.
What do mock audits do?
Mock audits mimic the process and procedures of an actual government audit but are conducted by internal or external resources that provide Medicare Advantage program audit assistance instead of government auditors. The goal of a mock audit is to identify and correct any operational or regulatory deficiencies before an actual government audit takes place.
Medicare Advantage mock audits are essential for MAOs to maintain compliance with the Centers for Medicare and Medicaid Services (CMS) requirements and regulations, which can be complex and constantly evolving.
Mock audits also provide an opportunity for MAOs to evaluate their internal processes, procedures, and documentation to ensure that they accurately capture and report all required information to the CMS.
Process of Medicare Advantage mock audits
The mock audit process typically involves a comprehensive review of all relevant records, data, and reports, including member enrollment, claims, medical records, financial records, and contracts. The auditor will also review operational policies and procedures, as well as documentation related to program integrity and medical review.
During a Medicare Advantage mock audit, the auditor will look for specific areas of potential risk and vulnerabilities that could impact compliance with CMS regulations. These may include issues related to:
- Enrollment
- Claims
- Coding and billing
- Medical necessity
- Utilization review
- Fraud and abuse
The auditor will also evaluate the MAO's internal controls and systems to determine if they are practical and reliable enough to detect and prevent errors or fraud.
The final results of a mock audit are used to help MAOs identify areas that need improvement and implement corrective action plans to address any deficiencies. The findings are also used to help MAOs prioritize their efforts and resources to ensure they are fully prepared for an actual government audit, making Medicare Advantage program audit assistance a critical service for any medical facility.
Final thoughts
Medicare Advantage mock audits play a crucial role in maintaining compliance with CMS regulations and preventing the integrity of the Medicare Advantage program. By conducting mock audits, MAOs can proactively identify risk areas and implement corrective action plans to avoid costly penalties and fines associated with non-compliance.
In addition, mock audits provide valuable information and insights that help MAOs continually improve their internal processes and systems to ensure they meet all CMS requirements and deliver the best possible care to their members.
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