Latest Audit Enforcement Actions Issued by CMS

Like clockwork, the Centers for Medicare & Medicaid Services published the enforcement action notices issued to sponsors related to 2017 program audits. Additional detail regarding conditions, audit scores, and enforcement is expected to be included in the 2017 Program Audit Enforcement Report, which the agency hopes to release before their conferences taking place May 9-10. In the meantime, we break down the published data, which includes not only program audit actions but others as well:

  • Eighteen sponsors were issued almost $2.6 million in Civil Money Penalties (CMP) between September 2017 and February 2018 based on their 2017 program audit findings.
    • 72% of sponsors cited for Coverage Determinations, Appeals, and Grievances violations
    • 61% of sponsors cited for Formulary and Benefit Administration violations
    • 39% of sponsors cited for Organization Determinations, Appeals, and Grievances violations
    • 22% of sponsors cited for Part C Beneficiary Protections/cost sharing violations
  • A Program of All-inclusive Care for the Elderly (PACE) sponsor was issued a CMP in November of 2017, and two PACE sponsors had enrollment suspended in the fourth quarter of 2017.
    • PACE plans: You are small but have a mighty sense of responsibility. If you have not done so already, review the posted enforcement notices, distribute within your organization, and create an action plan if you identify any similar findings.
  • One Prescription Drug Plan sponsor had enrollment suspended due to medical loss ratio.
  • Two sponsors were issued CMPs in 2017 based on outlier status of auto-forwards to the Independent Review Entity.

CMS noted in their draft call letter the agency is considering adding a CMP icon in Medicare Plan Finder (MPF) starting in 2019. If the agency proceeds that way, sponsors undergoing audits this year and incurring CMPs will be impacted by this new indicator. We support efforts such as this which promote beneficiary transparency. As I outlined in our analysis, sponsors should take note. Low Performing Icon information has not been limited to the MPF. Marketing organizations and other industry publications have taken that information and run with it, which may give an advantage to competitors of affected plans. In a recent Bloomberg Law article, I further discuss enforcement actions and the implications of this Low Performing Icon.

Remember that enforcement actions can be levied not just for program audit performance but also for a host of other violations. While I have provided some recent statistics, an analysis of actions taken year over year show patterns in some regards, and no rhyme or reason in other regards. Don’t spend too much time slicing and dicing these figures for your management; let us do that here in these articles. Focus on plan performance and continuous improvement. The goal should be to ensure your organization does not end up with enforcement actions in the first place.




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