Developing Tool to Perform Audit Sampling Simulations
Model alternative sampling approaches for healthcare audits and estimate their effect on audit outcomes
Challenge
As part of its oversight of Medicare Part C, CMS conducts audits of risk adjustment payments made to health plans. These audits involve significant operational effort, including medical record review and stakeholder outreach. Before launching an annual audit cycle, CMS must determine which sampling strategy will provide the most meaningful view of program performance and compliance risk. Understanding how different audit approaches may influence audit findings and oversight outcomes is critical to ensuring that audit resources are used effectively.
Approach
Emendata created a simulation tool that allows CMS to assess potential audit strategies before they are implemented. The tool provides a flexible framework for designing, testing, and comparing alternative sampling approaches. Its modular architecture supports simultaneous testing of new sampling methodologies, while parallel processing enables large-scale simulations to be completed on the timelines required for program operations.
Outcome
By modeling how different approaches may affect audit results, the tool has helped CMS understand the tradeoffs associated with alternative audit designs as it makes decisions. The framework has been used to assess the potential impact of numerous sampling approaches and audit specifications, providing an efficient way to evaluate proposed changes before they are implemented. These analyses help CMS focus its resources on the strategies that best support its program integrity goals.