Keeping you updated on the latest Medicare and Part D news

CMS Audits of Medicare Health Plans Find Serious Violations, Result in Civil Fines and Sanctions

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A recent New York Times article recaps findings from federal audit reports of Medicare health plans, notably the serious areas of noncompliance and resulting penalties.


• In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.

• When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.

• In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.

Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.


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