On October 29th, 2014, Chinese Community Health Plan (CCHP) was notified that they were being put on immediate imposition of intermediate sanctions from the Centers for Medicare & Medicaid Services (CMS). The Medicare sanction was triggered by what the CMS auditors concluded were severe violations in the Chinese Community Health Plan Medicare Advantage (MA-PD) plans offered in San Francisco County. Download the CMS sanction letter at the end of the post.
CCHP’s Deficiencies Create a Serious Threat to Enrollee Health and Safety
CCHP has experienced widespread and systemic failures impacting CCHP’s enrollees’ ability to access prescription medications and medical services. CCHP has inappropriately denied payment for emergency or urgently-needed medical services and failed to obtain concurrence from physicians responsible for beneficiary care before discharging from the inpatient hospital level of care. CCHP has denied enrollee’s access to services and medications by failing to provide transition supplies of medication to enrollees in accordance with the CMS transition policy and through significant failures within their appeals and grievances process. – CMS letter to CCHP, 10/29/2014
Chinese Community HP immediate sanctions
The immediate intermediate sanctions means that CCHP must cease all marketing and enrollment of their MA-PD plans until CMS lifts the sanction. The sanctions against marketing and enrollment can last up to a year. Current Members of the CCHP MA-PD plans will still receive services and are not impacted by the sanctions.
CMS enumerated 29 different violations of Medicare regulations during an audit in late July and early August. For the Part C or health coverage of the CCHP MA-PD plan, CMS found –
- Inappropriately denying payment for emergency or urgently-needed medical services.
- Failure to obtain concurrence from physicians responsible for beneficiary care before discharging from the inpatient hospital level of care.
- Inappropriately issued a Notice of Denial of Medical Coverage to enrollees during inpatient hospital stays without advising them of their right to file an immediate review with the quality improvement organization (QIO).
- Failure to authorize or pay for medically necessary and/or covered medical services.
Among the prescription drug coverage of the MA-PD CMS found –
- Failure to demonstrate sufficient outreach to prescribers or beneficiaries to obtain additional information necessary to make appropriate clinical decisions.
- Failure to notify beneficiaries of its decision within 24 hours of receipt of expedited coverage determination requests or exceptions requests.
- Improperly denying coverage determinations by failing to consider prior use of medication and clinical information.
Chinese Community Health Plan opportunity to correct
In the sanction letter CMS notes the sanctions will remain in effect until CCHP can prove that the deficiencies have been corrected and are unlikely to recur. While CCHP has seven days to file a corrective action plan by November 6, 2014, they can request additional time. The intermediate sanctions that prevent marketing and enrollment are fairly severe as they can significantly impact the number of members and revenue for the contractor of the MA-PD plan put on sanction.
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