Helaine I. Fingold, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore office, was quoted in RADAR on Medicare Advantage, in “2019 Part D Misclassifications, Formulary Issues Fueled CMPs,” by Lauren Flynn Kelly.
Following is an excerpt:
2019 Audit Cycle Focused on Large Firms
That year-over-year difference stems from the fact that the 2019 audits focused on some of the largest plan sponsors/parent organizations, explains Helaine Fingold, a member of the Health Care and Life Sciences practice at Epstein Becker Green. Although CMS last year may have audited a smaller number of firms than in 2018, it “reached a much larger footprint with respect to enrollment,” including organizations such as Humana Inc., UnitedHealth Group and CVS Health Corp. (Aetna), observes Fingold. Based on CMS enrollment figures from December 2019, she estimates that the audited firms collectively served nearly 34 million Medicare enrollees (compared with 39 audited organizations serving approximately 806,000 members in the 2018 audits).
“For 2019, the bases for the CMPs moved back towards the Part D area, which had been a problem area for many plans in past years,” remarks Fingold in an email to AIS Health. For example, noncompliance in FA drove half of the CMPs issued that were based on 2019 audit findings, with noncompliance related to Part C or Part D organization/coverage determinations, appeals and grievances “being the next most common basis,” she says. …
“With an increase in compliance issues in the formulary and benefits area, plan sponsors must ensure that they are appropriately monitoring and auditing their Pharmacy Benefit Managers,” advises Fingold.