Helaine I. Fingold, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Baltimore office, was quoted in AIS Health, in “2022 Medicare Advantage Audit Report Reflects Modest Penalties, Familiar Failures,” by Lauren Flynn Kelly. (Read the full version – subscription required.)
Following is an excerpt:
There wasn’t much to be gleaned from CMS’s latest annual report on program audits of Medicare Advantage and Part D sponsors, and CMS wants it that way. According to the 2022 Part C and Part D Program Audit and Enforcement Report, published on July 18, just three MA insurers received a civil monetary penalty as the result of a program audit last year, with the average CMP around $21,000 — compared with an average of $65,247 in 2021 and $200,000 in 2019. CMS in the report said the amount of the CMP “does not automatically reflect the overall performance of a sponsor” and, similar to last year, warned against reaching “broad conclusions about the significance of deficiencies or performance across” the MA, Part D or Medicare-Medicaid Plan (MMP) programs. ...
Helaine Fingold, member of the law firm Epstein, Becker & Green, P.C., points out that unlike prior audit enforcement reports, the 2022 report excluded the names of the parent organizations that were subject to audits and did not provide the overall and program area audit scores. (Audit scores are based on the number and types of non-compliant conditions discovered during the audit.) Meanwhile, only one entity was subject to an enforcement action in the form of an enrollment suspension due to financial solvency, while 2022 enrollment suspensions for failing to meet medical loss ratio requirements were imposed on five organizations. …
“Some common deficiencies cited in the 2022 report were not dissimilar to those noted in prior years’ program audits,” remarks Fingold. “For example, plans applied incorrect UM edits to their CMS-approved formulary, plans did not meet appeals and grievances timelines, and ODAG [Part C Organization Determinations, Appeals, and Grievances] denial notices were insufficient or unclear. Other deficiencies noted included plans’ failure to ensure that monitoring and auditing systems were comprehensive or current, failure to quickly address and correct compliance issues, and failure to address the root cause.”
