bionbabe.blogg.se - Common audit findings

#COMMON AUDIT FINDINGS HOW TO#
#COMMON AUDIT FINDINGS SOFTWARE#

Ensure that all grievances, including single call resolution grievances, are properly documented and counted as grievances in all required reporting.

Ensure that members are properly offered the option to initiate an organization determination or redetermination when applicable, and the offer is documented in the case notes.

Particularly when multiple issues are presented by the member.

#COMMON AUDIT FINDINGS HOW TO#

Ensure all associates are properly trained on how to populate the denial letters with the correct template or detailed denial information specific to the members case.Ĭommon Finding: Sponsor failed to correctly determine whether the issues in members’ complaints met the definition of inquiries, grievances, organization determinations, appeals, or a combination of the preceding and, therefore did not resolve the complaints or disputes through the appropriate procedures.Case review should target a variety of utilization management, safety related and exception cases.Ĭommon Finding: Sponsor did not include in its denial letters adequate rationales, correct complete information specific to denials, or language easily understandable to members.

Perform daily, weekly or monthly oversight of the denial letter content to ensure all required information and criteria is included on the letters for the member to gain an approval.Review alternate non-English language letters to ensure the entire letter is translated into the applicable language, including the description of denial.This should include all language versions of the templates. Review denial letter templates on a regular basis to ensure they contain the minimum required information found on the CMS denial templates.Ensure all associates are properly trained on how to populate the denial letters with the correct template or detailed denial information specific to the enrollees case.Secret Shopping and Tele-Sales Recorded Call Review for AEP & OEPĬommon Finding: Denial letters did not include adequate rationales, contained incorrect/incomplete information specific to denials, or were written in a manner not easily understandable to members.Risk Adjustment Operational Assessment & Comparative Analysis.Medicare Bid Development and PBP Review.Medicare Applications and Implementations.Interim Staffing and Permanent Staffing Assistance.Health Care Policy Analysis and Application.Credentialing Audits and Policy Reviews.Call Center Assessment & End-to-End Monitoring.Vendor (FDR) and Internal Oversight and Monitoring Programs.Comprehensive Oversight and Monitoring Programs.STAR Rating Projection and Gap Analysis.Plan Performance in Quality (Stars/HEDIS/Gaps in Care).Part C End-to-End Part D Claims Processing Audit.Part D End-to-End Part D Claims Processing Audit.PBM RFP Development, Review, and Contracting.Policy and Procedure Development and Refinement.

#COMMON AUDIT FINDINGS SOFTWARE#

Part C & D Claim Testing and Monitoring Software.Audit Preparation and Onsite CMS and State Audit Support.