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CMS hits Humana with $3.1 million penalty for Medicare Advantage, drug plan violations

Penalty is single largest imposed against 129 organizations found in violation of Medicare Advantage, prescription drug plans.

Susan Morse, Managing Editor

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The Centers for Medicare and Medicaid Services has levied a $3.1 million penalty against Humana, the single largest imposed against 129 organizations found in violation of Medicare Advantage and prescription drug plans in an audit.

Humana's civil penalty was based on an audit of its Medicare operations from April 20, 2015 through May 7, 2015, CMS said. Humana's systemic failure in complying with requirements related to Parts C and D resulted in enrollees experiencing inappropriate delays or denials in receiving covered benefits or increased out-of-pocket costs, CMS said.

Other organizations with fines at a million or above in actions taken in 2015 or 2016 include: Medical Card System, $1.29 million; Envision Pharmaceutical Services, $2.59 million; and Aetna, $ 1 million.

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The March 3 release of the civil penalties, along with a list of organizations receiving suspension of enrollment and marketing activities, furthers CMS's goal of improving industry standards and providing continued transparency, according to Jerry Mulcahy, director Medicare Parts C and D Oversight and Enforcement Group, who sent out the notice to all Medicare Advantage organizations.

The civil money penalties were imposed for violations related to failure to comply with Part D formulary benefit administration; Part C and Part D organization/coverage determinations, appeals, and grievances; and invalid data submissions.

[Also: Universal Health Systems' behavioral health centers under investigation for alleged billing fraud]

Actions in 2015 and 2016 for suspension of enrollment and marketing were levied against: Torchmark Corporation, Cigna-HealthSpring, and Ultimate Health Plans.

Those cited with suspension of enrollment in 2015 or 2016 included: HealthPlus of Michigan (which received a sanction release), and Alexian Brothers Community Services.

CMS said it plans to post civil money penalty enforcement actions to its website within the first quarter of the following program audit year. For 2016 program audit violations, violation notices will be posted in the first quarter of 2017 to allow the public and plan sponsors to more easily compare  the audit violations, CMS said.

Correction: SilverScript Insurance Company should not have been included in HFN's list of organizations receiving recent 2015 or 2016 CMS suspensions from enrollment or marketing.

Twitter: @SusanJMorse