The CMS jumped out of the gate in 2015 with a spate of fines for noncompliant Medicare Advantage and Part D plans, but that pace didn't hold up for the rest of the year.
In 2015, the CMS issued $4.72 million in civil monetary penalties to insurers that offer private Medicare and prescription drug plans, down from the $4.93 million in fines imposed in 2014. The CMS has used fines and the more serious enrollment sanctions in recent years to crack down on plans that don't follow Medicare's coverage rules.
The decreased quantity of fines doesn't mean the government is easing off the enforcement pedal. Several observers believe the previous penalties have forced insurers to improve their operations.
“It's not that CMS is letting up,” said Mark Joffe, an independent attorney based in Washington, D.C., who works with Medicare health plans. “My guess is CMS is finding that plans realize that these types of errors are taken very seriously and what you need are checks and double checks.”
When asked if plans were getting better at compliance or if oversight was tapering off, a CMS spokesman said: “We haven't completed all 2015 audits.”
Richard Lieberman, chief data officer at Mile High Health Analytics, said the lower penalty amount in 2015 likely means plans have taken CMS' enforcement message to heart. He also believes the CMS will continue to monitor several Medicare issues closely.
One primary issue is drug formularies. Most of the fines and enrollment sanctions dished out over the past two years have involved unclear or inaccurate prescription drug information. For example, seniors enrolled in Medicare Advantage and Part D may have been inappropriately denied their medications, mistakenly used an out-of-network pharmacy because it was marked as in-network or didn't have the resources to file a grievance. Drug access is vital for seniors, and the CMS has said it does not want private payers impeding that access.
“CMS gets infuriated when a member goes to a pharmacy counter and can't get their meds,” Lieberman said. “CMS is really going to come down hard on that.”