Auditing & Validation

Acumen has several teams dedicated to auditing and validating health care program data to promote compliance with and integrity of various Medicare programs. This work often involves auditing the accuracy and availability of marketed plan benefits and services and reviewing marketing materials and communication to enrollees to ensure that health plans are meeting compliance standards.

Additionally, when Medicare tests care delivery models and payment systems outside of the traditional fee-for-service system of reimbursement, Acumen often supports these programs by verifying the complex calculations that determine payments to providers and health plans. In performing these audits, Acumen not only verifies the accuracy of the arithmetic and adherence to the prescribed methodology of the calculations, but also conducts conceptual validations to identify methodological challenges of these programs that have often led to significant policy changes.

 

Case Study

Part D Formulary and Benefits Assessments (2008-Present): Prepared for the Centers for Medicare & Medicaid Services, Division of Formulary and Benefit Operations

In conjunction with Centers for Medicare & Medicaid Services (CMS), Acumen monitors the marketing and adjudication of Medicare Part D prescription drug formularies and benefits to ensure the quality and integrity of the program. CMS performs these reviews to ensure that plans offer appropriate drug coverage and benefits for Part D beneficiaries and that they are administering benefits in accordance with regulation.

To safeguard beneficiaries’ coverage under their Part D plans, Acumen leverages its expertise in benefit and formulary structures to investigate areas where Part D plans may be noncompliant with Medicare’s policies. To conduct these validations, Acumen develops processes to regularly collect data samples from Part D plans, such as rejected prescription drug claims or marketed formularies, assess the validity of these data samples, and identify areas of concern. These processes investigate:

  • Are any Part D plans unjustly denying beneficiaries prescription drugs that are essential to their care?
  • What formulary or plan benefit designs encourage discriminatory practices against certain types of patients?
  • How are beneficiary enrollment and drug utilization impacted by the removal of certain drugs from a plan’s formulary?

Such analyses have a direct impact on the success of the Medicare Part D program. Over time, Part D plans’ performance in these analyses has improved and the results of the analyses have been adopted as Display Measures by CMS. As Display Measures, the results for each Part D plan are made publicly available to prospective enrollees, allowing the public to make informed health care choices and supplying an incentive for Part D plans to comply with program policies.