CMS is sanctioning Elevance Health and plans to suspend enrollment into the insurer’s Medicare Advantage prescription drug plans, according to a Feb. 27 agency letter.
The enrollment and communications pause is set to begin March 31 unless Elevance submits all data corrections and an attestation in advance. CMS said the intermediate sanctions stem from “substantial and persistent noncompliance with Medicare Advantage risk adjustment data submission requirements.” The sanctions will apply until Elevance resolves the issues.
According to CMS, Elevance submitted data corrections for unsupported diagnosis codes from November 2018 until October 2025 through encrypted external USB flash drives instead of the appropriate electronic systems. During that time period, the company reportedly sent seven letters to CMS saying it did not plan to submit data corrections through CMS systems. Dates of service for these “potentially unverified diagnosis codes” ranged from 2015 through April 2023. CMS sent six letters directing Elevance to comply.
Since Elevance did not use the correct systems, the company violated its obligation to report and return overpayments within 60 days, CMS said.
CMS also alleged that the company continued to annually certify the accuracy of its risk adjustment data while knowing that unverified diagnosis codes had not been corrected through the required systems.
Elevance said it is reviewing the Feb. 27 letter from CMS.
“We stand firmly behind the compliance and integrity of our Medicare Advantage program, which is supported by rigorous oversight, comprehensive monitoring and established governance processes,” an Elevance statement shared with Becker’s March 2 said. “We value our longstanding relationship with CMS and will continue to engage constructively and transparently. Our focus remains on delivering high-quality coverage and service to our Medicare Advantage members.”
Elevance had 1.9 million Medicare Advantage members as of Feb. 1.
