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Recent Industry News

Government Auditors

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The Centers for Medicare and Medicaid Services (CMS) recently fined 17 health plans for violating Medicare prescription drug rules.  CMS has enforcement and contractual authority, which includes the discretion to impose Civil Money Penalties and/or suspend Medicare Plan Sponsors for non-compliance with the regulations.  CMS’s 2016 program audits revealed that half of the 37 audited health plans that offered Medicare prescription drug benefits improperly denied beneficiaries access to drugs and other services.  As a result, CMS imposed financial penalties on these plans.

UnitedHealthcare, the nation’s largest insurer, received $2.5 million in penalties for failing to comply with several Medicare prescription drug requirements.  CMS found violations in 56 of UnitedHealthcare’s Medicare Advantage and Part D contracts, including inappropriate denial of drug coverage for plan members with acute conditions requiring immediate attention.  Some plan members did not receive their medications.  Several members also experienced delayed access to medications and unnecessary increases in out-of-pocket costs.

Examples of other plans that received penalties include the following:

  • WellCare Health Plans – $1,174,300;
  • Presbyterian Health Plan – $775,375;
  • AvMed – $764,375;
  • Community Care HMO – $760,500; and
  • Centene Corp. – $31,950.

A list of recent CMS enforcement actions is available at:

https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/PartCandPartDEnforcementActions-.html.

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