CMS has made clear in recent months, if not years, that it considers problems Medicare Part D enrollees have in getting prescriptions filled promptly and at the proper price to be a high priority. But just in case any Medicare Advantage or stand-alone Prescription Drug Plan (PDP) sponsor hasn't gotten the message, what CMS did late last month will change that. The agency determined that UnitedHealth Group owes the feds $2,175,000 in a civil money penalty (CMP) stemming from numerous alleged Part D violations it found in an audit at United's Minnesota headquarters last October. And it appears unlikely that United will contest the findings.
Industry observers do not recall any fines of this magnitude for Part D violations previously, although Health Net, Inc. incurred marketing and enrollment sanctions that began in 2010 and ended last year for Part D access-related problems, and Quality Health Plans, Inc. was hit with a $586,000 CMP in 2010, among other plans penalized. There should have been little doubt that this was an enforcement priority for CMS even before its action against United, but there should not be any doubt now. The agency cited "multiple, serious violations of Part D requirements" at United, including rejecting prescriptions at the point of sale as not being on United's formulary when they were, failure to follow CMS requirements regarding transition supplies of prescription drugs for new enrollees, and improper application of step-therapy and prior-authorization criteria in "edits" at the point of sale.
Why do you think Part D plans seem to continue to have problems in this area? Since CMS has made clear it expects the plans to make sure their contracted PBMs follow the rules, are plans just not able to police the PBMs adequately? And will the size of this penalty, even though it might constitute just a "rounding error" for giant United, help change the level of compliance?