The Centers for Medicare and Medicaid Services most recent Medicare Advantage (MA) audit, which covered approximately 30 percent of MA Part C and Part D contracts, found significant problems with plan compliance and formulary administration. Specifically, the audit found that “[s]ponsors applied utilization management edits that were not part of their CMS-approved formulary.” The audit also found that plans often did not meet timeframes for making redetermination decisions as it related to appeals and grievances; and when exception requests were granted, the exception did not apply for the entirety of the plan year. Lastly, the report highlighted the multiple areas in which CMS used its enforcement authority to impose civil money penalties. Civil money penalties were imposed for inappropriate cost sharing for Part D medications and Part C items and services; inappropriate denials of Part D medications at the Point of Sale; inappropriate Part D Premiums; and inappropriate denials of Part D coverage determinations. Read the full audit report here.
Last Updated on August 4, 2023 by Aimed Alliance
