2024 Audit Changes

In the last two blogs, we explored trends that we saw while working with partner PACE organizations during their audits over the course of 2023 as well as ways to navigate the intensity of PACE program audits for better operations moving forward. Today, we will explore some expected changes in the year ahead, not necessarily to the audit itself, but due to regulatory changes that will impact the process.

What drives changes in regulation usually are the patterns and observations that emerge from past and current audits. For PACE programs, CMS will audit new programs and existing programs and, based on their findings, CMS will then clarify or revise regulations in response to any trends or patterns that appeared. In other words, if the audits show significant challenges or levels of non-compliance, you will see changes in regulations to provide more clarity for all programs.

PACE Provider Network

One of the areas of regulatory change that will happen in 2024 is around the provider network. The expectation is that a PACE program has a provider network that meets the needs of its participants in a timely manner. In the past, a program could add a participant with a need and contract with a provider soon AFTER enrollment. Now, the program will need the provider contracted BEFORE a participant can be enrolled. This will require programs to be more proactive to predict the future needs of participants to keep enrollment timely. This will also require programs to promptly communicate to CMS and the State Administering Agency any contracting issues that potentially impact a participant’s access to needed care and services.  

PACE programs are already required to have a provider network that covers 26 specialties specified in the regulation, which includes the addition of palliative care. However, that list is not exhaustive of every participant’s particular needs so this adjustment would apply to services beyond the core 26. For instance, if the program wanted to enroll a participant with substance use disorder, they would need to contract with a behavioral health provider trained in substance use BEFORE enrolling that participant or be able to ensure substance use disorder services are met through a different mechanism until a contracted provider is in place. Similarly, if a participant needs dialysis, a contract with a dialysis provider would need to be secured before enrolling that participant. We expect these additional service needs to vary from program to program, based on their population’s needs.

Immediate Civil Monetary Penalties

Another significant regulatory change is related to civil monetary penalties including suspension of enrollment and/or payment. Programs have always been subject to these, but there was time to respond and modify to avoid a monetary penalty. The new changes would allow a civil monetary penalty for certain circumstances without adding a 30-day window to correct the deficiency. This will be reserved for situations in which there are significant deficiencies in the quality of care furnished to participants or the PO failed to substantially comply with conditions of a PO agreement. It will be even more important for programs to be in compliance to avoid these penalties.

Prepare for Future Regulatory Changes

The above two changes are part of five that were codified for 2023 and 2024. The other three include changes in the program contract year definition addressing timing issues pertaining to trial period audits and ensuring POs have sufficient time to enroll and gain adequate program experience prior to their first trial period audit; administrative flexibility  in the service determination request process that allows for oral or written notification in the case of an extension; and affording POs more operational flexibility in how they maintain written communications relating to participant care, health, or safety. All provisions in the final rule take effect January 1, 2024; however, changes to the contract year definition and the provision of service determination requests were applicable June 5, 2023.

In addition to the five codified, CMS had proposed a total of 15 other regulatory changes. Our expectation is that some of the remaining 10 may be implemented later in the coming year and/or early 2025, so it is important for all programs to monitor and be ready to adjust and comply.

Intus Care will be following any new regulatory changes throughout the year and will be a resource to our partner PACE organizations to help with compliance.  

Want to see how Intus Care can help your organization with compliance among other needs? Take our self-assessments that cover topics such as data-driven culture, quality processes, CMS compliance risks, PACE operations, and utilization management. Our Integrated Care Services team will provide tailored recommendations based on your responses.