Tips to Improve Medicare-Medicaid Integration Using D-SNPs: Using Medicare Program Audit Reports to Improve Managed Care Organization Oversight

ICRC Tip Sheet
Publisher: Washington, DC: Integrated Care Resource Center
Jun 30, 2018
Ryan Stringer and Nancy Archibald

Key Findings:

  • Medicare program audits may reveal authorization, appeal, and grievance issues, inadequate compliance program mechanisms, and care coordination issues that impact Medicaid benefits.
  • States can find audit summary information for Medicare Part C and Part D sponsors from prior year audits on the CMS Medicare program audit results website.
  • States can use their contracts with D-SNPs or contact MMCO to obtain full Medicare program audit reports.
The Centers for Medicare & Medicaid Services (CMS) periodically conducts Medicare program audits of organizations sponsoring Medicare Advantage plans, including Dual Eligible Special Needs Plans (D-SNPs). To help oversee their contracts with D-SNPs and Medicaid managed care organizations, states may find Medicare program audit reports issued by CMS, available from the Medicare-Medicaid Coordination Office (MMCO), to be useful tools. States can use the results of Medicare program audits to identify performance issues impacting dually eligible beneficiaries’ receipt of care coordination, long-term services and supports, durable medical equipment, and other services, and incorporate that information into their audit and oversight activities. Insights from Medicare program audits can help states and CMS to coordinate their audit activities in order to improve D-SNP performance across Medicare and Medicaid benefits.