CMS Puts Plans on Notice with Recent Enforcement Actions

The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded readers, have been asked, “What will it cost us if we stay non-compliant?” By the numbers:

• Just under $7.3 million in penalties were levied between October 2016 and February 24, 2017.
• 37 sponsors were audited, with a combined total of 115 contracts.
• The active contract with the smallest enrollment has 93 members (as of February 2017).
• The largest audited contract has almost 2.9 million members (as of February 2017).
• The 2016 average audit score was 1.22, a decrease from the 2015 average of 1.76.
• There are over 11.5 million members currently enrolled in a plan levied a Civil Money Penalty (CMP) for Contract Administration. That’s the population of Ohio, or 11 Rhode Islands¹.

CMP data points tell us not to focus on the score, the plan’s enrollment size, or number of contracts – none of this will alone tell the outcome of CMPs. There were a number of sponsors audited in 2016 with similar violations yet not issued CMPs, including violations which appear on CMS’ ever-referenced common conditions.

Do you delegate most key member-facing functions? Is there a palpable culture of a focus on other lines of business? Has your enrollment grown too quickly for operations to adjust? Are you in the midst of organizational changes? What have you done to prepare for your audit, or better yet, timeliness reviews? What do you plan on doing with this knowledge?

¹Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2016, US Census Bureau

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