(Prescription drugs denied: Centene faces CMS penalty)
Centene Corporation was fined by the Centers for Medicare and Medicaid Services (CMS) for violating Medicare Part D and its Benefit Administration Plans. Centene’s noncompliance with the Prescription Drug Rules and its execution process resulted in a $57,660 Civil Money Penalty (CMP) for Medicare Part D breaches and a $215,000,000 CMP for Benefits Administration Plan violations, according to CMS.
Centene was found in breach of Part D of Medicare, which includes the CMS authorized list of medications, access, and refusal of prescription drugs, and appeal and grievance rights, during a routine program audit from May 16, 2016, to May 27, 2016. Martha Smith, senior vice president, Medicare Solutions, Centene Corporation, received a notice of the civil money penalty from CMS.
The imposition of CMPs resulted in a 40-point drop in the company’s star ratings on the Beneficiary Access and Performance Problems assessment, damaging its reputation.
Prescription medicine access delays and denials
Prescription drug coverage is available to all Medicare beneficiaries in the United States. Sponsors or health insurance firms who sell these Medicare plans must sign contracts with the CMS to ensure they follow all statutory, regulatory, and sub-regulatory requirements and that prescription medications are available.
Centene Medicare members delayed access to prescription medications at the point of sale and had little alternative except to obtain these prescriptions independently, resulting in increased out-of-pocket payments.
Centene’s list of prescription medicines it covers was never submitted to CMS for approval. The corporation actively disobeyed the prior authorization process, causing difficulties for its Medicare members in obtaining numerous prescription medications.
CMS has a system to ensure that enrollees have a smooth transition from formulary to non-formulary medications. On the other hand, Centene did not follow the transition process, providing subscribers insufficient time to switch to a medically equivalent prescription or request an exception to keep their current medication covered.
Enrollees faced delays or denials in receiving approved prescription drug benefits, resulting in high out-of-pocket costs. Furthermore, registrants were primarily barred from selecting refills for medications that had obtained PA approval.
The CMS audit report revealed this willful violation of the Medicare Prescription Drug Benefit Manual while implementing the benefit plan for a smooth transition policy and effective prior authorization implementation.
Inadequate rights to file a complaint and appeal
Every Centene Medicare plan enrollee has the right to contact his sponsor if he is concerned about coverage denial or an operational issue. Centene should classify all such complaints according to their nature and respond accordingly. They are anticipated to perform a first-level review known as Coverage Determination if any complaints are received.
According to the CMS audit, Centene did not correctly examine these concerns, prompting its members to seek justice through the Independent Review Entity (IRE). Centene’s procrastination in resolving the grievances caused life-threatening conditions and healthcare risks by delaying access to medically necessary or life-sustaining drugs.
Centene’s reputation was harmed as a result of the penalty.
Several state and federal agencies have fined Centene Corporation for repeatedly violating state healthcare regulations. Centene has been sued by unhappy employees and stockholders for violating the Fair Labor Standards Act and the Investor Protection Act, in addition to Medicare Part C, D, and Benefit Plan Administrator Violation.
Since 2000, Centene has submitted a total penalty of $715,826,709, out of which it has paid:
- $58,644,042 for consumer protection-related offenses;
- $215,000,000 for benefit plan administrator violation;
- $210,340,000 for investor protection violation;
- $47,934,042 for insurance violation; and many other violations and offenses.
If Centene continues to violate Medicare Part D, the CMS can impose intermediate fines on the corporation. These fines could include deferring marketing activities and future enrollment and payment, leading to contract termination.
