A new report issued October 16, 2014 by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) reveals that civil monetary penalty (CMP) enforcement actions in these two programs more than tripled from 2012 to 2013. The majority of these enforcement actions were referrals related to Part C and Part D program audits conducted by MOEG, which evaluates sponsors’ compliance with core program requirements, including the sponsors’ ability to provide beneficiaries with access to medically necessary services and prescription drugs.

Most violations (89%) cited in recent enforcement actions have been ones that resulted in inappropriate delay or denial of beneficiary access to health services or medications. According to the report, the most frequent violations leading to enforcement actions occurred in the areas of Part D coverage determinations, appeals, and grievances; formulary and benefit administration under Part D; and Part C organization determinations, appeals, and grievances. In 2012 and 2013, the report states that CMS has imposed 43 CMPs totaling $8.36 million on 39 different organizations. CMPs have ranged from just over $20,000 to more than $2 million.

By the end of 2014, MOEG projects that it will have audited 54% of all Medicare Advantage, Medicare managed care, and Prescription Drug Program organizations, accounting for 96% of total beneficiary enrollment in these programs. The report also describes MOEG’s audit methodology. A copy of MOEG’s 2013 Part C and Part D Program Annual Audit and Enforcement Report is available by clicking here.

Reporter, Susan Banks, Washington, D.C., +1 202 626 2953, sbanks@kslaw.com.