So this audit is it a pass or fail type thing? What happens if you fail a CMS audit?
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Also, I didn’t see it noted but after the last failed audit, we were not able to take on new customers during AEP for at least one year. Maybe two? I forget.
Any concern this audit could result in us being in sanctions again?
'“ What happens if you fail a CMS audit?”
Big fines'
Before any type of fine, you will be asked for an action plan to remediate first of all and company audit specialist will be assigned to meet with your team.
Very brief audit description...CMS picks a 'universe' of cases over a time period (i.e. 3 months). The ESI or Cigna Medicare team pulls all work completed for those cases and reviews them for possible concerns that CMS may find. Action plan is developed. Meet with CMS. Findings produced. CMS follow up meeting then to agree upon changes to move forward. There will be another surprise audit in future. They don't just show up. You will be given a short notice however.
Cigna has failed an Audit before and has been put on a CAP (corrective action plan) it took several years for Cigna to prove to CMS that it improved. So poor leadership is in the DNA of Cigna Medicare as we have failed before and we might fail again. We worked hard to revamp and change many things before our last program audit. We passed fairly well (2019), but many of the people who managed that program audit are now gone (older staff who were job eliminated) and new poor leadership has crept back up again. However, I feel the DNA of previous strong leadership still lives on and we are in a better place than before. I am worried as we have a new set of people at the driver seat. I can say we genuinely did improve many things, however CMS can n-p pick anything they want so who know what will happen.
Hey Cigna Leaders, when you start eliminating jobs with experienced SME's, you will increase risk of failing or scoring poorly on an audit. I know it wasn't Medicare leaders choose to eliminate jobs. they simply were following Cigna Cooperate directive.
“ What happens if you fail a CMS audit?”
Big fines