PART C AND PART D 2014 PROGRAM AUDIT RESULTS

The Centers for Medicare & Medicaid Services (CMS), Medicare Parts C & D Oversight and Enforcement Group (MOEG) is responsible for conducting program audits for Medicare Advantage (MA) and Prescription Drug (Part D) plans to ensure compliance with CMS requirements. The figures below represent the overall and individual program area audit scores for each of the sponsors audited in 2014. In 2014, CMS utilized a scoring system that generated an audit score for every sponsor based on the number and severity of non-compliant conditions detected in a sponsor’s operations. In this scoring system, a lower score represents better performance on the audit (see Final Program Audit Scoring Methodology for the complete scoring methodology). Because the audit score is generated based on the number of non-compliant conditions discovered, the maximum audit score is unlimited. Accordingly, the highest scores listed in the charts below are the highest scores sponsors received in 2014, not the highest possible scores. A score of “0” on the audit would indicate there were no conditions of non-compliance discovered on the audit. The figures on the following pages array the 2014 overall and individual program area audit scores in order of best performance to worst performance (i.e., lowest score to highest score) moving from left to right across the graph. The average audit score across all audited sponsors is represented by the orange line in each graph. The average audit score for audited sponsors with a high star rating (4.5-5 stars) is represented by the green line. Please note that some of the audited sponsors were not audited for a given program area. In such instances, the sponsor is excluded from the given program area graph.

https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/HPMS-Memo-Final-Program-Audit-Scoring-Methodology.pdfhttps://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Downloads/HPMS-Memo-Final-Program-Audit-Scoring-Methodology.pdf

0.31 0.40 0.40 0.48 0.55 0.61 0.80 1.06 1.15 1.35 1.42 1.44 1.55 1.61 1.85 1.86 1.90 1.90 1.95 2.10 2.35 2.36 2.37 2.39 3.00 3.09 3.25 0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50A

udit

Scor

e

Overall 2014 Audit Score by Sponsor*

Average 1.61 High Star Average 1.00

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited in 2014. The High Star average is an unweighted score across those sponsors with a STAR Rating of 4.5 or greater.

0.00 0.25 0.25 0.33 0.50 0.50 0.50 0.50 0.75 0.75 1.00 1.00 1.00 1.00 1.25 1.50 1.50 1.50 1.75 2.00 2.25 2.50 2.50 3.00 3.75 4.50 5.00 0.00

1.00

2.00

3.00

4.00

5.00

6.00

Aud

it Sc

ore

Part D Formulary and Benefit Administration (FA) 2014 Audit Score by Sponsor*

Average 1.53 High Star Average 1.25

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited for the FA program area in 2014. The High Star average is an unweighted score across those sponsors audited for FA with a STAR Rating of 4.5 or greater.

0.00 0.33 0.33 0.33 0.67 1.00 1.33 1.67 2.00 2.00 2.00 2.00 2.33 2.67 3.00 3.00 3.33 3.33 3.33 4.00 4.33 4.33 4.67 4.67 6.33 8.33 12.33 0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Aud

it Sc

ore

Part D Coverage Determinations, Appeals and Grievances (CDAG) 2014 Audit Score by Sponsor*

Average 3.10 High Star Average 1.60

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited for the CDAG program area in 2014. The High Star average is an unweighted score across those sponsors audited for CDAG with a STAR Rating of 4.5 or greater. Note that the average CDAG audit score decreases to 2.74 when excluding the score for Summa Health System.

0.00 0.25 0.25 1.00 1.25 1.25 1.50 1.50 1.75 2.25 2.33 2.33 2.50 2.67 3.00 3.75 4.00 4.00 4.00 4.50 4.50 5.67 9.67 0.00

2.00

4.00

6.00

8.00

10.00

12.00A

udit

Scor

e

Part C Organization Determinations, Appeals, Grievances, & Dismissals (ODAG) 2014 Audit Score by Sponsor*

Average 2.78 High Star Average 1.80

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited for the ODAG program area in 2014. The High Star average is an unweighted score across those sponsors audited for ODAG with a STAR Rating of 4.5 or greater. Note that the average ODAG audit score decreases to 2.47 when excluding the score for Chinese Hospital Association.

0.00 0.00 0.22 0.22 0.22 0.33 0.33 0.33 0.44 0.44 0.44 0.67 0.78 0.78 0.78 0.89 1.11 1.22 1.22 1.22 1.22 1.33 1.44 1.44 1.44 1.56 1.78 0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

Aud

it Sc

ore

Part C and Part D Compliance Program Effectiveness (CPE) 2014 Audit Score by Sponsor* Average 0.81 High Star Average 0.33

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited for the CPE program area in 2014. The High Star average is an unweighted score across those sponsors audited for CPE with a STAR Rating of 4.5 or greater

1.00 1.00 1.00 1.00 1.33 2.67 3.33 3.33 0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

UAB HealthSystem

Elderplan, Inc. SouthwestCatholic Health

Network

Inland EmpireHealth Plan

SWH Holdings,Inc.

Chinese HospitalAssociation

AlohaCare Local InitiativeHealth Authority

for LA County

Aud

it Sc

ores

Special Needs Plans - Model of Care (SNP MOC) 2014 Audit Score by Sponsor*

Average 1.83

*A lower audit score represents better audit performance. The average audit score is an unweighted score across all sponsors audited for the SNP MOC program area in 2014. There is no High Star average for SNP MOC as no High Star sponsors were audited for this program area in 2014.