The Centers of Medicare and Medicaid Services (“CMS”) requires that organizations contracted to offer Medicare Part C and/or Part D benefits, be subject to an independent yearly review to validate data reported to CMS on a variety of reporting for Part C & Part D measures with the exception of PACE organizations and Part C Health Care Prepayment Plans. The data validation is “retrospective,” referring to the fact that it normally occurs in the year subsequent to the measurement year. Data Validation audits are typically conducted onsite or virtual with sponsoring organizations in April and May with final report submissions due to CMS by June 30th.
For Part D specifically, any organization that delegates services to a Pharmacy Benefit Manager (“PBM”), or other delegated entity such as an MTM vendor, must have the data validation contractor it hires include the data & reporting processes for which the PBM/delegated entity is responsible in its data validation review.
The validated data improves reporting and provides CMS with assurance that data is credible and consistent from sponsoring organizations. CMS uses these reported data to respond to inquiries from Congress, oversight agencies, and the public about an organization’s performance. The validated data also allows CMS to monitor and compare the performance of sponsoring organizations over time.
The purpose of the independent data validation is to ensure that Part C & Part D organizations are reporting health and drug plan data that are reliable, valid, complete, comparable, and timely. Part C & Part D sponsoring organizations are responsible for contracting with an independent data validation (“DV”) contractor such as PillarRx to conduct the CMS-required annual validation of Part C and D Reporting Requirements data. CMS provides a set of standards as guidance for organizations and contractors to follow. Sponsoring organizations assist the DV contractor in obtaining the information, data, and documents needed to complete the DV review. Mock audits can also be conducted prior to the formal DV period, but that organization must be different from the organization performing the formal DV review.
PillarRx has been assisting sponsoring organizations with data validation services since the inception of the Data Validation CMS requirement back in 2011. At PillarRx, our data validation team has over 20 years of COMBINED experience within data validation and various other auditing services, which speaks to our understanding and experience with how the program has evolved over time to better anticipate CMS’s next move.
For more information about DV Services or how PillarRx can assist with your plan’s Medicare compliance, contact us at [email protected]
Part C and Part D Data Validation, https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/PartCDDataValidation