2019 Program Audits Reflect Continued Improvement

CMS’s latest overview of program audits showed continued improvement among Medicare Advantage and Part D organizations, with the average overall audit score dropping from 1.03 in 2018 to 0.77 in 2019. Scores improved across all program audit areas except for two — Part D Formulary and Benefit Administration (FA) and Special Needs Plan Model of Care (SNP-MOC) — results that hint to sponsors where CMS is directing its energy, suggests one compliance expert.

According to the 2019 Part C and Part D Program Audit and Enforcement Report issued Sept. 14, the CMS Medicare Parts C and D Oversight and Enforcement Group (MOEG) imposed a total of $1.6 million in civil monetary penalties (CMPs) on eight sponsors in 2019. Two of those CMPs, however, were related to noncompliance identified outside of program audits. Fines based on program audits alone amounted to about $1.2 million, or an average of nearly $200,000 per organization, compared with an average CMP of about $41,000 for the 2018 program audits, which focused on smaller plans (RMA 3/7/19, p. 3).

© 2021 MMIT

Lauren Flynn Kelly Managing Editor, Radar on Medicare Advantage

Lauren has been covering health business issues, including drug benefits and specialty pharmacy, for more than a decade. She served as editor of Drug Benefit News (the predecessor to Radar on Drug Benefits) from 2004 to 2005 and again from 2011 to 2016, and now manages Radar on Medicare Advantage. Lauren graduated from Vassar College with a B.A. in English.

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