Plans' misclassification of Part D
coverage determinations and/or redeterminations appears to be the most
frequently cited audit finding in 2017, according to a preliminary AIS Health
analysis of available civil monetary penalties (CMP) notices.
A total of 18 sponsors were issued a CMP between September 2017 and February 2018, according to a Feb. 26 memo from the Medicare Parts C and D Oversight and Enforcement Group. The 18 insurers were fined approximately $2.4 million based on 2017 audits, according to AIS Health's analysis of notices posted to the CMS Parts C and D Enforcement Actions webpage.
Magellan Health, Inc. subsidiary Merit Health Insurance Co. received the largest fine — $1,368,200, which is significantly lower than the $2.5 million penalty that UnitedHealth Group received last year.
"It is critical for a sponsor to properly classify each complaint as a grievance, organization/coverage determination, or both," advised CMS in its letters to plan sponsors. "Improper classification may result in enrollees not receiving the required level of review, and/or experiencing delayed access to medically necessary or life-sustaining treatments."
CMS also cited eligibility issues in CMPs. Derek Frye with The Burchfield Group said, "Coordinating eligibility data among all three parties (the plan, CMS, and Medicaid) creates complexity [that] can manifest especially during a member's new eligibility with a plan, which also coincides with their transition period, causing inaccurate application of transition benefits."
Other common issues include violations related to formulary and benefit administration, and failure to provide enrollees transition supplies.
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