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3 tips for nailing your plan’s next CMS program audit

Audits are constant. And being constantly ready is critical. Prime’s proactive approach to audits helps our health plan clients rest easy — these tips can help you successfully navigate your next audit.


Audit results don’t garner huge headlines or notoriety. But maybe they should. The Centers for Medicare and Medicaid Services (CMS) program audits provide an honest gauge of a plan’s operational preparedness, compliance and performance. The impact can be far-reaching — business continuity, corrective actions and all of the associated costs.

One of Prime’s largest clients recently underwent a CMS program audit. Prime was an integral part of helping the client prepare for and navigate the audit, with many successes along the way. It didn’t happen by chance, a number of Prime teams prepared with lots of hard work and pre-audit reviews. Here a few of our top tips for achieving audit success:

  1. Be audit ready all the time.
    Alexander Graham Bell once said, “Before anything else, preparation is the key to success.” Take it seriously. To stay ready, Prime performs of number of mock client audits each year, on top of our own preparation and monitoring. When an audit happens, we have dozens of practiced experts at the helm to support our clients in helping audits run smoothly and efficiently.

  2. Have a defined audit management process — and follow it.
    Audit timelines are short. Having a solid audit management process helps keep deliverables on-track and on-time. But issues still can and do arise. Expect them, and have processes in place to identify and resolve them as early as possible. At Prime, we have a team that proactively monitors potential issues. These efforts help our clients rest easy, and trust that we’re providing needed audit support.

  3. Strive for high-quality, sound operational compliance — every day.
    Compliance is essential to successful health plan operations and successful audit outcomes. Sound operational compliance not only sets the stage for smoother audits, it contributes to operational excellence, higher Star ratings, and fewer findings, corrective actions and monetary penalties. 

Because of our preparation, Prime’s client received a 100 percent accuracy scoring for the coverage determinations timeliness review during a recent audit. CMS said they don’t recall any plan ever receiving a score that high.

Callout: Because of our preparation, Prime’s client received a 100 percent accuracy scoring for the coverage determinations timeliness review during a recent audit. CMS said they don’t recall any plan ever receiving a score that high.

About Prime Therapeutics

Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves nearly 26 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing private companies in the nation.  

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