Medicare Part C and D Data Validation Audit

Medicare Part C and D Data Validation Audits (DVA) are required by the regulations (42 CFR 422,516, 422.514, CMS-4085-F) implemented by the Centers for Medicare and Medicare Services (CMS). In order to ensure the independence of the Data Validation Audit, organizations cannot use their own staff to conduct it. Instead, Medicare Advantage Organizations (MAO) and Part D sponsors are required to contract with independent external data validation auditors to review the process and data that is reported to CMS.

Medicare Audits

Madena is pleased to offer a Medicare Part C and Part D Data Validation Contractor Audit program that incorporates our extensive industry experience.

What We Bring to the Data Validation Audit Process
  • Thorough understanding of Part C and Part D reporting requirements and technical specifications.
  • Subject matter expertise related to areas concerning Title I and II of the Medicare Modernization Act (MMA), Medicare Part C and Part D regulations, Medicare Managed Care Manual, and Prescription Drug Benefit Manual.
  • Experience in conducting internal audits for various business operations including functions related to Medicare enrollment/disenrollment, grievance and appeals, etc.
  • Extensive experience in reviewing systems and processes, including systems for claims, enrollment, provider data, grievance and appeals, pharmacy data, etc.
  • Over eight years of experience with source code review, which includes developing and reviewing complex source code for performance reporting for Medicare Organizations.
  • Thorough familiarity with various software programs and query languages including, SQL, SAS, Brio, Crystal reports, Cognos, MS Access, Excel, etc.
  • Experience in statistical analysis.
  • Completion of all required CMS Data Validation trainings.
Protecting your data is a top priority.

In addition, all Health Plan data is housed in SSAE-16 and HITRUST certified servers, which demonstrates a high level of compliance with HIPAA and the HITECH Act. Madena continually updates the staff training for HIPAA Compliance and has active monitoring tools in place.

Madena has the necessary background and skills to successfully assess Data Validation standards.

Madena has been dedicated to auditing and consulting with managed care organizations and pharmacy benefit managers for over eight years. We have worked with clients of all sizes, from new start-ups to some of the largest Medicare managed care organizations in the country.

A core audit team is assigned to each data validation audit to serve as the primary reviewer. Additional Madena staff resources for source code review and census/sample validation will be included in the audit review team. Access to greater staff expertise allows for efficient completion of documentation review and responses to your communications throughout the process.

Madena is committed to involving clients throughout the process and keeping them informed of any possible findings. Madena will share a regular issue log, timeline, and status of key deliverables to help clients manage expectations as well as highlight any concerns about documentation submitted and reviewed. There will be no surprises on the final report. Madena conducts your Data Validation review in an open, efficient, and reassuring manner.

Data Validation clients can expect the following in our service:
  • Kick-off Data Validation webinar to ensure transparency and agreement with the process
  • Review and feedback of the Organizational Assessment Instrument
  • Source code review
  • Full census file review/recalculation
  • Onsite or virtual meeting with Primary Source Verification
  • Ongoing tracking of issues, deliverables, and plan review of draft findings prior to submission to CMS
  • Final Validation Report and Work Papers
  • Ad-hoc webinars and/or teleconferences as needed to facilitate the Audit process

by Sue Dahlkamp, Interim Compliance Officer and Director, Operations

Author: admind