CMS has fined 13 health plans a combined $1.5 million for Medicare Advantage program violations spanning cost-sharing rules and Part D drug benefit administration.
The penalties, issued May 1, stem largely from claims processing system errors that caused enrollees to pay more than they should have for medical services and prescription drugs, in some cases exceeding annual out-of-pocket limits. CMS identified the violations through audits of plan year 2022.
In January, the agency issued nearly $2.5 million in fines to seven insurers for MA contract violations.
Thirteen latest fines:
CVS Health was fined $753,805 for overcharging enrollees due to multiple claims processing errors, including improper application of payment reduction methodologies, incorrect provider designations, outdated fee schedules, and miscategorized claims for mental health services.
Centene was fined $380,785 for overcharging enrollees for outpatient services due to a claims processing system error that applied incorrect copays, and by charging enrollees more than the annual maximum out-of-pocket limit due to failures in tracking and entering cost-sharing accumulations.
Group 1001 was fined $84,190 for overcharging enrollees due to claims processing errors affecting provider payment rates and plan enrollment, and by charging enrollees more than the annual maximum out-of-pocket limit due to system errors that mistracked out-of-pocket accumulations.
Arkansas BCBS was fined $57,757 for overcharging enrollees due to multiple claims processing errors, including a misconfigured traveler benefit, incorrect fee schedule rates, improper application of the lesser-of-usual-charge rule, and errors in Merit-based Incentive Payment System rate adjustments.
Health Care Service Corp. was fined $50,437 for overcharging enrollees due to errors in processing physical therapy assistant claims and applying an incorrect fee schedule for durable medical equipment and enteral nutrition claims.
UnitedHealth was fined $48,869 for overcharging enrollees for medical surgical supplies, having improperly calculated coinsurance using billed amounts rather than allowed amounts.
Security Health Plan was fined $29,005 for overcharging enrollees due to a claims system that could not detect duplicate services billed by different providers, and by charging enrollees more than the annual maximum out-of-pocket limit due to multiple system and manual processing failures.
ATRIO Health Plans was fined $21,847 for charging enrollees more than the annual maximum out-of-pocket limit due to system errors that excluded certain emergency room cost sharing from out-of-pocket accumulators and failures in manual claims processing.
Devoted Health was fined $18,668 for charging enrollees more than the annual maximum out-of-pocket limit, stemming from a weekly rather than real-time transmission of out-of-pocket accumulator data to delegated entities and the absence of a reconciliation process.
Memorial Hermann Health Plan was fined $16,676 for charging enrollees more than the annual maximum out-of-pocket limit due to a technical error in the insurer’s legacy claims adjudication system during a system transition that caused 2022 claims processed in 2023 to be overcharged.
EmblemHealth was fined $11,648 for overcharging enrollees for Part B drugs due to a manual configuration error that caused the plan to pay providers 33% more than the intended reimbursement rate.
Blue Shield of California was fined $10,988 for violating Part D rules by failing to reprocess prescription drug claims within 45 days of receiving updated low-income subsidy eligibility information, resulting in enrollees being overcharged for Part D drugs.
Highmark was fined $10,458 for violating MA and Part D rules by overcharging enrollees for medical services due to a facility class code omission in its claims system, and for failing to process retroactive low-income subsidy adjustments within required timeframes following a data transfer failure during a contract acquisition.
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