The Centers for Medicare & Medicaid Services (CMS) has posted information regarding agency audit and enforcement initiatives pertaining to Medicare Advantage (MA) and Prescription Drug Plan (PDP) organizations conducted since January of 2006. CMS is charged with overseeing the operations of MA and PDP organizations that have contracted with CMS to provide Medicare services and prescription drugs to Medicare beneficiaries. CMS carries out this obligation, in part, through ongoing monitoring efforts which include periodic performance audits. The posting of CAP data reveals (i) the type of conduct the agency has been auditing or monitoring; (ii) the basis for any enforcement action pursued; (iii) the penalty or other consequence imposed; and (iv) any remedial action or other effort required by CMS based on agency findings.
While several of the reports are designed to summarize overall efforts by CMS, others provide specific detail by organization on perceived deficiencies, the Corrective Action Required (CAR), and the status of the CMS inquiry. Interestingly, the nature of the deficiencies are extremely varied and include both Medicare Part C and Part D issues. A review of this detailed information should be useful to plan sponsors, PBMs and other downstream entities, including retail pharmacies, as these entities consider and track similar issues within their organizations.
Enforcement, audit information, and related CAP summaries can be found at: http://www.cms.hhs.gov/MCRAdvPartDEnrolData/CAP/. Once you locate the web page, scroll down and click on the Corrective Action Plan link.
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