CMS proposes updates to audit Civil Monetary Penalties

Medicare plans and pharmacy teams are being heavily scrutinized by the Centers for Medicare and Medicaid Services – now more than ever before. The changes CMS has implemented for 2019 as well as upcoming proposed changes for the next few years suggest that plans are more likely to be audited than not.

An audit is certainly a black mark on a health plan. It’s stressful. And, it can be expensive.

CMS audit penalties have cost health plans as much as $375,000. In mid-March, the agency released a proposal updating its civil monetary penalty listings for last year’s audits – and the fines are all higher per enrollee. An overview:

Per Enrollee Penalty Amounts in 2017 and 2018

– Standard Penalty: $200

– Aggravating Factors: $100

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $25

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $15

Penalty Amounts for 2019-2021

– Standard Penalty: $212

– Aggravating Factors: $106

– Untimely/Inaccurate Beneficiary Communications Standard Penalty: $27

– Untimely/Inaccurate Beneficiary Communications Aggravating Factor: $16

Why is CMS raising the fines? That remains to be seen. Among other things, officials take into account inflation and cost-of-living adjustments.

CMS plans to release a final plan in April.

Audits are usually conducted once every between three to five years. There are different types, including CMS program audits, PDE audits, one-third Financial audits, BID audits, Formulary Administration audits, Transition Monitoring Program Analysis, Coverage determination/redetermination Timeliness audits and Data Validation audits.

It’s important to be ready at all times for an audit – especially if your health plan has performance issues or has faced CMS oversight in the past.

Plans that do not have a vigorous auditing and monitoring program are at risk of non-compliance with CMS regulations – and resulting fines. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The audit process is extensive, and tough to do when you’re trying to run your plan every day. And, don’t forget, plans only have three weeks from the time they receive an audit notice to be ready for it to get underway. You’re going to need help – and that’s where we come in.

The team at Tier 1 Pharmacy Consulting provides support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to ensure compliancy and get you through the process.

Get in touch today – before an audit notice lands on your doorstep and costs your plan hundreds of thousands of dollars or more.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

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