In recent weeks, 17 private insurers that provide drug coverage to seniors through Medicare Advantage and Medicare Part D plans were on the receiving end of notification letters informing them that the Centers for Medicare and Medicaid Services (CMS) was imposing civil monetary penalties for noncompliance with a range of Medicare prescription drug regulations. The fines follow a 2016 audit of 37 health plans. The 17 insurers were fined a total of $7.3 million. UnitedHealthcare was hit the hardest with a fine of $2.5 million, followed by WellCare Health Plans ($1.1 million), with Presbyterian Health Plan, AvMed, and Community Care HMO (all above $750.000), rounding out the top five.

The audits uncovered a number of compliance failures on the part of the insurers. Violations of the prescription drug requirements led to reduced access to medical services and drugs, the CMS said. Some of the issues cited, included:

  • Inappropriate denials of coverage
  • Mandating prior authorizations under circumstances that are not subject to that process
  • Delayed access to medications
  • Beneficiaries who never received their medications
  • Beneficiaries who had to pay higher out-of-pocket costs than necessary
  • Failure to contact prescribers for additional information about prescription drug orders
  • Misclassification of coverage determinations
  • Failure to clarify appeal rights and processes

The fact that nearly half of the 37 insurers audited by CMS failed to pass muster and are now on the hook for significant penalties should once again serve as a wake up call regarding the importance of taking a proactive approach to Medicare compliance.