CMS’ Recent Enforcement Actions Show Agency Means Business in 2017
As we predicted, the Centers for Medicare & Medicaid Services (CMS) is off to an aggressive start on the compliance front in the last year of this administration and shows no signs of slowing down with $832,250 worth of fines levied in the month of February alone. The list of enforcement actions released comes with even graver announcements of two immediate suspensions of enrollment and marketing for the year. These fines augment two huge penalties with which CMS closed out last year − $3.1 million and $1.3 million.
In recent news, CMS did announce it will revise its policy of automatically reducing the Star Rating of sanctioned contracts to 2.5 stars. Effective immediately, CMS will suspend this policy, and will re-examine its approach in the 2018 Call Letter. This is a bit of good news for plans currently suspended from marketing and enrollment activities.
From the Medicare Advantage (MA) Advance Notice and Call Letter, we glean further insight into CMS’ agenda for 2016. CMS stressed its commitment to improving beneficiary protections for 2016. CMS stressed its plan to increase severity of compliance and enforcement actions in Parts C and D. Particularly, CMS pointed out their commitment to increase the severity of compliance and enforcement actions for Part D auto-forwarded cases, as they saw no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations in the past several years, despite continued warnings issued to organizations. CMS’ warning also extends to audits and enforcement actions in network adequacy, provider directory adequacy, and medication therapy management programs.
Given this strong warning, it is no surprise most of the civil money penalties (CMPs) levied in February were due to audits of benefit administration in Part D which showed “inappropriate delays of Part D benefits and increased out-of-pocket costs.” Several fines were also levied on Part C appeals and grievances and benefit administration.
Enhancing its theme of focusing on getting plans to tighten up their compliance programs, CMS will issue a memo of their interpretation of methodology for CMPs given the large amount of questions CMS receives related to CMP calculations, not so coincidentally, right before an audit.
CMS has also added a new avenue for enforcement actions — one-third financial audits. CMS is required to conduct these audits for 30% of MA plans each year and has announced they will move to include these in enforcement actions, including CMPs and sanctions, and not just corrective action plans.
If you think 2015 was bad with over $13 million in fines, 2016 is poised to be a record year for enforcement actions. If you’re not ready yet, now is the time to cross your t’s and dot your i’s and get your compliance program in order and prepared for what is positioned to be a busy year.
Resources
GHG’s renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>
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