Centers for Medicare and Medicaid Services slaps WellCare Health Plans with $1.17 million fine over drug coverage
Audit found WellCare didn't inform beneficiaries about coverage for certain prescription drugs, and denied prescription coverage, CMS says.
The Centers for Medicare and Medicaid Services has hit WellCare Health Plans with a $1.17 million fine after an audit revealed the insurer failed to comply with several requirements concerning beneficiaries and their prescription drug benefits.
The Sept. 2016 audit found that WellCare didn't inform beneficiaries about coverage for prescription drugs not covered under its formulary, and denied prescription coverage based on inadequate information, CMS said in a Feb. 23 notice.
WellCare of Tampa, Florida focuses on government-sponsored managed care services, primarily through Medicaid, Medicare Advantage and Medicare prescription drug plans.
[Also: Healthcare costs will outpace Medicare Advantage payments in 2018, report says]
Because of WellCare's improper prior authorization process, beneficiaries were delayed or denied access to prescription drugs, had to receive formulary alternatives, or pay out-of-pocket to receive their drugs, CMS said.
The insurer failed in having a timely exceptions approval process so that beneficiaries had to go through the process a second time, CMS said.
WellCare also failed to conduct outreach to enrollees to obtain additional information necessary to make an appropriate clinical decision, CMS said. As a result, enrollees' requests for coverage did not undergo a second-level review and when the request for coverage was denied, enrollees did not receive an explanation of their rights to file an appeal, CMS said.
[Also: CMS tests new model to lower cost of prescription drugs]
WellCare is reportedly reviewing the notice. An appeal must be filed by April 25.
Twitter: @SusanJMorse
