Hey Medicare Nation!
Here I am bringing you yet another Medicare Advantage Plan Sponsor, being slapped by CMS, for failing to comply with Medicare requirements related to Part C (Medicare Choice) and Part D (Medicare Prescription Drug Plans).
Today, I will be discussing the CMS Civil Money Penalty (CMP) that was imposed on Fallon Community Health Plan.
On June 29, 2017, a letter was issued to Mr. Richard Burke, the President and CEO of Fallon Community Health Plan, from Vikki Ahern, Director of the Medicare Parts C and D Oversight and Enforcement Group.
The letter was written relating to a "Notice of Imposition of Civil Money Penalty for Medicare Advantage-Prescription Drug Contract Numbers: H2411, H2470 and H9001.
Summary of Noncomplliance
CMS conducted an audit of Fallon's Medicare operations from February 16, 2016 through February 26, 2016.
In the audit report issued on July 20, 2016, CMS auditors reported that Fallon failed to comply with Medicare requirements related to...."Part C and Part D organization/coverage determinations, appeals and grievances in violation of 42 CFR" (Code of Federal Regulations).
The audit report lists the exact subsections of 42 CFR that were violated
The letter goes on to state....Fallon's failures in these areas were systemic and resulted in enrollees inappropriately experiencing delayed or denied access to benefits and/or increased out-of-pocket costs.
CMS made a determination to impose a civil money penalty (CMP) for Fallon's failure to comply, in the amount of $344,100.00.
That's a BIG fine!
Fallon Comunity Health Plan was founded in 1977. They have a product portfolio of group and individual health plan options.
Fallon also has a Senior Care Services Division, oversees all products, programs and solutions which focus on the senior population.
If you are a member of a Fallon Medicare Advantage Plan and you have questions regarding your plan, I would call the Senior Care Services Division.
The number is - 800-868-5200.
If you are a current member of a Fallon Medicare Advantage Prescription Drug Plan, your benefits are intact and working for you.
The $300,100 CMP was issued due to the incorrect classifications of "grievances", "organization determinations" for Part C complaints or "coverage determinations" for Part D complaints by members.
These incorrect classifications resulted in members not receiving the required level of review, and/or experiencing delayed access to medically necessary or life-sustaining treatments.
How does something like this happen, you may ask?
Insufficient training of Fallon customer representatives and agents.
Employers like Fallon, need to ensure their employees are properly trained in CMS Medicare Advantage Plan and Medicare Part D regulations as well as Fallon's Medicare Health Plans and benefits.
Train your employees Fallon!
Fallon needs to ensure their employees are competent and complying with Medicare rules & regulations relating to Medicare Advantage Part C and Medicare Part D.
What Should You Do if You or Your Parent(s) are on a Fallon Medicare Advantage Prescription Drug Plan?
Pay attention to your MONTHLY Explanation of Benefits (EOB) letter.
Look the document over and ensure all the prescriptions you filled that month are correct!
Look and make sure the provider(s) listed on your EOB are doctors or facilities you visited. Ensure any treatments or diagnostic tests were ones you actually did!
If you find a discrepancy, call Fallon customer service to notify them of it.
A Fallon customer service rep should be able to assist you with this issue.
If Fallon customer service is unable to assist you or if they refuse to assist you, you have two good options:
1. Call your Medicare Agent or Medicare Advisor. They enrolled you in the Fallon Medicare plan and should be a liaison between you and Fallon.
2. Call Senior Medicare Patrol.
Senior Medicare Patrol (SMP) is an awesome resource that is available to you for free!
SMP Volunteer's are seniors and understand what you're going through. They are trained to investigate or notify the agency who can investigate, suspicious or fraudulent charges on your EOB statement.
Go to the SMP website to find an SMP location near you:
If you believe you were denied coverage or delayed in receiving your benefits, you have a right to appea
Ask your Medicare Agent or Medicare Advisor to assist you and explain your options.
Your coverage and benefits are intact and not in danger at Fallon Health Plan.
Fallon has the right to appeal the CMS CMP by August 29, 2017.
We'll see what happens.
In the meantime, due your due-dilligence and monitor your EOB statements no matter which Medicare Advantage or Medicare Prescription Drug Plan you are on.
Report any discrepancies or suspicions right away.
I am available for consultations if you feel you have been denied a claim or your benefits were delayed due to an incorrect classification.
I also can initiate a reconsideration appeal for Part C claims or a redetermination appeal for Part D claims.
Contact me at Support@TheMedicareNation if you'd like me to consult with you.
Thank you for listening to Medicare Nation!
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Questions about Medicare or your Medicare Plan you need answered?
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Have a very happy, peaceful and prosperous week everyone!