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A Comprehensive Medicare Audit Checklist for Your Care Management Program

Audits are essential to any federally-funded healthcare initiative, including care management programs like Chronic Care Management (CCM) and preventive services like Annual Wellness Visits (AWV). Providers must comply with certain regulations and requirements to receive reimbursements from the Centers for Medicare & Medicaid Services (CMS). Periodic Medicare audits help maintain the highest standard of care for patients and ensure documentation and billing practices align with CMS guidelines.

While an audit might sound daunting, a proactive approach to compliance makes the process straightforward. Audit-ready processes help your practice mitigate risks, streamline operations, and continue delivering high-quality care to Medicare beneficiaries.

In this comprehensive guide, we will equip you with tools and information to anticipate audit requests, prepare effectively, and remain compliant with Medicare requirements. Our CMS audit checklist offers a helpful resource for staying organized and efficiently managing compliance with your care management program.

What are Medicare audits?

Medicare audits are reviews conducted by CMS to ensure healthcare providers comply with care, billing, and documentation requirements. Audits help verify that Medicare funds support better health and outcomes for eligible beneficiaries. Federal funding, including Medicare reimbursements, stems from taxpayer dollars. So, efficient and proper use of this money is essential.

During an audit, CMS assesses whether or not a care management program meets the program-specific requirements. Maintaining compliance helps you avoid penalties, financial losses, and reputational damage while ensuring uninterrupted patient care.

Importance of audits for your care program

Regular internal and external audits offer reputational, patient care, and administrative advantages, which can strengthen and improve your care management program.

Prevent penalties. Care management programs that fail to comply with CMS requirements may become subject to costly penalty fees, which CMS calls Civil Money Penalties (CMP). Penalty amounts depend on the infraction but can total thousands or even hundreds of thousands of dollars. Routine internal audits help providers proactively identify issues that could trigger penalties.
Maintain reputation. Non-compliance with CMS guidelines can be grounds for exclusion from federal healthcare programs and disrupt patient services. Audits help identify errors before they undermine patient trust and affect your organization’s reputation.
Improve patient care. CMS care management programs, like CCM and AWV, are rooted in evidence. They are carefully designed to support better outcomes, reduce costs, and improve overall health. Audits help providers consistently meet Medicare standards and ensure patients receive the full breadth of support the programs intend.
Promote accurate billing. Audits serve as a check on financial integrity, flagging issues like over- or under-payment or other billing errors. Proper billing and coding practices reduce the risk of fraud and ensure providers receive full Medicare compensation for their work.

Audits offer critical accountability for healthcare organizations that receive federal funding. Even without a CMS audit, an internal review of care management processes can highlight weaknesses and opportunities for better compliance.

How to prepare for a Medicare audit

With the proper preparation, you can be well-positioned to demonstrate compliance during a Medicare audit. Follow these steps to reduce your risk.

1. Understand the CMS guidelines.

As simple as it sounds, knowing the relevant Medicare guidelines—and what they mean in practice—is one of the best ways to maintain compliance. Each care management program includes specific elements. For example, a CCM program must include patient access to a 24/7/365 care line, personalized care plans, and monthly patient care, among other requirements. Consider appointing an internal team member to manage compliance and stay abreast of program rules and changes.

2. Review and improve internal processes.

Medicare compliance must be an organization-wide effort. Embracing processes that promote organization and clear documentation is key to being prepared for a possible Medicare audit. Periodic review of team workflows can help illuminate areas of improvement and mitigate risk.

3. Keep detailed records.

When in doubt, document it. Demonstrating compliance during an audit is easier if your organization has already developed a culture of provider documentation. Everything from care plans and patient communication to accurate time tracking and services should be carefully recorded.

You’ll be well-prepared for an audit by maintaining precise, organized documentation. That’s one reason documentation is central to ChartSpan’s care management approach.

4. Leverage an EHR.

Technology is invaluable to any compliance effort. Lean on your electronic health record (EHR) as your single source of truth. Maintaining consistent, organized, and thorough documentation in the EHR makes it simpler to find and retrieve the correct information in the event of a CMS audit.

5. Run internal audits.

Avoid surprises by conducting mock audits internally. This process can help you fix compliance issues proactively before incurring damages or service disruption. Periodic internal audits can also unify your team and provide an opportunity to improve and realign around CMS requirements.

6. Partner with a full-service care management provider.

As a full-service Chronic Care Management provider, ChartSpan offers a dedicated care team to help you improve patient outcomes with comprehensive preventive care services. Partnering with a fully managed care management program reduces the burden of managing compliance rules and supports straightforward internal audits.

By sharing the responsibility for the care management program, you’ll gain the structure and support to prevent non-compliance. ChartSpan, for example, connects to many EHR systems, making it simple to securely access important information about care manager-patient interactions, care plan adjustments, and billable services.

As an outside CCM provider, ChartSpan can also offer a third-party perspective on best practices and a compliance-minded framework for care management program administration. We ensure that everything our care team does, from identifying eligible patients to collecting patient consent and designing care plans, is documented and shared with providers. We also have extensive knowledge of Chronic Care Management and can offer a program for your practice that meets all CMS requirements.

Learn how to choose a Chronic Care Management vendor for your practice →

Example focus areas of a Medicare Audit

While there is some overlap in CMS requirements, the exact guidelines to consider depend on the care management program or preventive services your practice offers. Two examples include Chronic Care Management and Annual Wellness Visits.

Chronic Care Management (CCM)

Chronic Care Management is a preventive care program designed to support Medicare beneficiaries with two or more chronic conditions. The program aims to improve quality of life, reduce acute care events, and boost health outcomes for eligible patients by managing symptoms and coordinating care.

A CMS audit of a CCM program might require the following:

Record of an initiating visit for new patients and all patients a provider hasn’t seen within the last year
Documented patient consent
Patient health and demographic information stored in an EHR
A comprehensive care plan, documented electronically
Medical oversight by appropriate clinicians
Evidence of 24/7 access to care
Clear documentation of care management and care transition services
Services and corresponding billing codes

For Annual Wellness Visits (AWV)

As the name suggests, an Annual Wellness Visit is a yearly appointment wherein a provider assesses overall health and risk factors for eligible Medicare patients. The AWV is intended to promote patient self-management and proactive, preventive health.

A CMS audit of an AWV might require:

Documentation of a Health Risk Assessment (HRA) for first-time AWVs
Documentation of the patient's family and medical history
Up-to-date list of patients’ current suppliers and providers
Updated screening schedule, including preventive care services
Record of provider recommendations on interventions for any identified risk factors
Evidence of appropriate referrals and interventions, including community-based interventions and self-management tools
Advanced Care Planning (ACP) information if applicable
Record of patient opioid use
Documentation of Substance Use Disorder (SUD) screens
Record of a Social Determinants of Health (SDOH) risk assessment

Verifying compliance with complex CMS requirements for a care management program can be challenging, but partnering with a fully managed CCM program provider helps reduce the burden. By offering a process that aligns with Medicare guidelines and a dedicated care team, a partner like ChartSpan shares the responsibility of compliance.

ChartSpan can also improve your audit readiness for Medicare initiatives like AWV. Our software offers a comprehensive Health Risk Assessment and identifies risk factors or gaps in care so providers can create a care plan. This detailed documentation and streamlined process help providers stay compliant.

Medicare audit checklist for CCM programs

Medicare audits involve reviewing some or all of your program procedures and documentation. If you are selected for an audit, CMS will notify your organization and request specific information, such as billing records or claims documentation. In the event of non-compliance, corrective action or penalties may follow; however, all audit decisions can be appealed through a specific process.

Regardless of your specific Medicare program and requirements, focusing on a few essential components in a CMS audit is important. Use this audit checklist to organize your information and anticipate CMS requests.

1. State licensure

Medicare requires that CCM services be performed by “clinical staff” under the supervision of the billing practitioner. CMS references the CPT codes, which defines “clinical staff” as someone who “works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service, but who does not individually report that professional service.” That means the licensure requirements for CCM clinical staff vary from state to state. Consult with state and local laws to determine the requirements for your practice. If applicable, retain evidence of the appropriate state licensure, such as RN, LPN, or LVN, in some states.

2. Patient eligibility

CMS audits may seek to determine whether the services provided were medically necessary and/or whether the services billed were for eligible Medicare patients. Different care management programs have different eligibility requirements. Providers must be prepared to demonstrate a clear and accurate record of the factors that qualify patients for Medicare reimbursement.

3. Patient consent

CMS requires verbal or written consent for care management programs. For example, for CCM, the patient must be notified of:

The availability of CCM services
Cost-sharing responsibilities
Enrollment under one CCM provider
The option to unenroll at any time

Be prepared to provide proof of patient consent during an audit.

4. Initiating Visit

An initiating visit is mandatory for new patients or those who have not seen their provider within the last 12 months. CMS does not require an initiating visit for patients who have had a visit in the previous year. Carefully track and document the initiating visit (if required) to remain compliant.

5. Care encounter documentation

In an audit, CMS may be interested in determining whether your services were covered under Medicare guidelines. Clear, thorough documentation of care services will help demonstrate your understanding of coverage and requirements.

6. Billing records

Sometimes, an audit may be designed to examine targeted billing issues and educate providers to improve compliance and reduce denials. Audits may also examine billing practices at random to look for coding errors. In either case, billing documentation should include the codes and medical records to support them.

7. Electronic health records

Be prepared to tap into your EHR for information requests ranging from billing codes to specific program requirements, such as a comprehensive care plan for CCM. Anything from the total time spent in face-to-face care to which specific billing codes are used for which patients falls under the purview of a CMS audit.

Improve compliance with ChartSpan's full-service CCM program and AWV software

Finding the right tools and partners is one of the best ways to put yourself in a Medicare audit-ready position. Our fully managed CCM program and our AWV software are designed around CMS guidelines, which takes the guesswork out of developing a compliant program or initiative. ChartSpan’s tools and services alleviate the burden of compliance and give you confidence in your processes and documentation.

Start a CMS-compliant CCM program

ChartSpan’s CCM program guides patients from eligibility and enrollment to care coordination, care planning, and communication—all in collaboration with providers. Our program includes:

24/7/365 access to care
Dedicated care managers
Medication management, appointment scheduling, and test result support
Comprehensive care plans
SDOH connections and resources

At every step of the process, we ensure proper documentation in alignment with CMS guidelines. Our program alleviates the stress and administrative weight of implementing CCM and supporting better patient care.

Learn more about our Chronic Care Management services →

Reduce the compliance headache of Annual Wellness Visits

Our AWV software is flexible enough to be tailored to your patient population but rigid enough to comply with strict CMS requirements. ChartSpan’s RapidAWV™ features:

A robust HRA tool, customizable to your patients
Timely reminders so you never miss the opportunity to schedule an AWV for an eligible patient
Comprehensive care plans aligned to CMS guidelines
Screening recommendations based on individual patient health risks

Because our software is designed around Medicare’s AWV billing requirements, our partners can have confidence knowing their process will set them up well for Medicare audits while saving them time and relieving the burden of additional work.

ChartSpan’s care management solutions simplify the compliance process, reduce administrative stress, and keep your practice audit-ready. Talk to a care management expert today to learn how our full-service CCM and AWV solutions can support your practice.

Learn more about our flexible Annual Wellness Visit software →

Talk with a ChartSpan Representative Today!

Table of Contents

Blog

A Comprehensive Medicare Audit Checklist for Your Care Management Program

What are Medicare audits?

Importance of audits for your care program