CMS has fined Health Net and Dallas-based Tenet Healthcare, which both operate Medicare plans, for wrongly denying coverage for prescription drugs and inappropriately delaying policyholder appeals.
Here are 11 things to know about the violations and fines.
Tenet
1. In a Feb. 29 letter to Matt Cowley, CEO of Tenet's Arizona health plan operations, CMS listed Tenet's Medicare Part C and Part D violations.
2. CMS identified a violation of Part D formulary and benefit administration requirements that resulted in Tenet's enrollees not receiving their requested medications or experiencing unnecessary delays after receiving a rejected claim.
3. CMS also fined Tenet for violations of Medicare Advantage appeal and grievance requirements. The violations may have caused enrollees to experience delays or inappropriate denials of medical services, according to CMS.
4. Tenet also failed to produce sufficient records for CMS to evaluate the quality and timeliness of services provided to Medicare enrollees.
5. As a result of the violations, CMS imposed a civil penalty of $127,200.
6. Tenet has 30 days to appeal the initial determination by CMS. If Tenet doesn't file an appeal, the full penalty is due May 2, according to CMS.
Health Net
7. CMS listed Health Net's Part C and Part D violations in a Feb. 29 letter to Jay Gellert, president and CEO of Health Net.
8. CMS identified a violation of Part D formulary and benefit administration requirements that resulted in Health Net's enrollees being delayed and/or denied access to covered drugs.
9. Health Net was also fined for violations of Part C and Part D appeal and grievance requirements.
10. As a result of the violations, CMS imposed a civil penalty of $458,250.
11. Health Net has 30 days to appeal the initial determination by CMS. If Health Net doesn't file an appeal, the full penalty is due May 2, according to CMS.
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