The Med Diva

An insider's guide to Medicare Part D and more

Archive for the tag “Centers for Medicare & Medicaid Services”

Medicare Drops the Ball on New Mail-Order Pharmacy Rule for Part D Members

Medicare drops the ball on seniors

I recently posted two articles about a new Medicare Part D rule that affected beneficiaries who get their medications delivered on a regular basis from a mail-order pharmacy. The rule, which went into effect on January 1, required all pharmacies with home delivery services to get direct consent from Part D plan members before shipping each and every medication.

Today I have some good news to share: The enlightened folks at Medicare have decided that — surprise, surprise — this new rule did not work as intended. Last week, much to our relief, the Centers for Medicare & Medicaid Services (CMS) rescinded the rule.

Full details are still pending, but as of now, you do not need to give your pharmacy permission to ship the medications you regularly receive by mail. It’s probably not quite as simple as this, so if I hear more, I’ll let you know.

If you’re still not familiar with the rule I’m referring to, I’m not surprised. Medicare did a very poor job communicating the details of the rule with Part D plans and beneficiaries.

In a nutshell, the rule required pharmacies to get consent from the plan member (by phone or online) every time the member’s doctor submitted a new prescription or a refill on an existing prescription was ready to be shipped. If the pharmacy didn’t get the member’s consent, it could not ship the medication. No consent, no medication. Period.

As soon as I heard about this rule back in November, I knew it was a recipe for disaster. This rule, I thought, had the potential to create a serious safety issue for seniors and other Medicare beneficiaries. I was right.

Without guidance and communications from Medicare, Part D plans and their members were left in the dark. I tried to provide clear information about the rule for our plan members, but even I found it too complicated to fully understand and explain.

By the first week of March – just two months after the rule went into effect – hundreds of thousands of prescriptions were being held up in mail-order pharmacies throughout the country. Medicare beneficiaries didn’t receive the medications they needed because they didn’t know about the rule or understand how to provide consent. I’m sure many people were very worried and confused when their medications didn’t arrive in the mail on time as expected.

So as I let out a huge sigh of relief, I have something to say to CMS: You really screwed up on this one. By not providing clear communications to Part D plans and members about this complex rule, you created a major safety issue for seniors. You didn’t think it through and consider all the logistics and implications. You dropped the ball and left it up to Part D plans and pharmacies to put it back in play, even though you didn’t provide the rules of the game.


New Government Rules Affect Medicare Part D Mail-Order Pharmacy Services

Medicare Part D

A few weeks ago I posted important news about a big change that affects Medicare beneficiaries who get their medications from a Medicare Part D mail-order pharmacy. Based on feedback I have received, many Medicare Part D plan members still do not understand how this rule affects them. That means a lot of people are probably wondering why they haven’t received their medications.

So let me try to help and explain this new rule again:

As of January 1, 2014, you must give your mail-order pharmacy permission to dispense and ship every prescription.

For example:
• If your doctor calls in a prescription, sends an e-prescription, or sends a prescription by fax to your mail-order pharmacy, you still need to give the pharmacy permission to process that order. This rule applies whether your doctor is ordering a NEW prescription or is RENEWING a prescription that has expired.

• If you normally get refills every three months, you will need to give the pharmacy permission every three months for every medication.

• If you were previously enrolled in an automatic refill service, you are no longer able to use this type of service.* Under this new rule, your prescription drugs can no longer be automatically refilled and shipped to your home.

NOTE: The pharmacy will not be able to ship your medication until you provide permission and confirm that you want to get the order.

When Do I Need to Give My Permission?

If you place your own order: If you order your own new prescriptions or refills by phone, mail, or pharmacy website, you DO NOT have to provide any additional permission. The fact that you ordered the medication yourself is considered “providing permission” under this new Medicare rule.

If your doctor places the order: If your doctor calls in a new prescription or faxes a prescription to the pharmacy, you will need to provide permission to confirm that you want this medication.

If you need refills: If you have a refill that is waiting to be shipped, you must give your consent and confirm that you want your prescription to be refilled.*

How Do I Give Permission?

Depending on your mail-order pharmacy, there are several ways to provide consent when your pharmacy receives an order from your doctor or has a refill waiting to be shipped:

Online: If your mail-order pharmacy has a website, you may be able to go online to provide consent for refills, new prescriptions, or renewed prescriptions.

Email: Your pharmacy may send you an email with a link to a website where you can provide permission.

Phone: Your pharmacy may provide a phone number to call or use an automated phone message that asks you to give your consent over the phone.

In any case, the pharmacy will need to get your consent before shipping every order, so make sure they have your most current phone number or email address. Until you give permission, your order will not be processed and your medication will not be shipped.

If you are currently using a Medicare Part D mail-order pharmacy, you should have received information by mail, phone, or email regarding this change in service. If you haven’t received any information about this new Medicare rule, you should contact your plan or your mail-order pharmacy to confirm that they have your correct contact information on file.

Why Did Medicare Establish This Rule?

Many mail-order or home delivery pharmacies provide a convenient refill service that automatically ships prescription drugs when the customer is about to run out of medication. Unfortunately, some Medicare Part D plans never checked to find out if their customers still wanted or needed their drugs. The automatic refill service was simply put on auto-pilot, so to speak, and would send the medication to the person’s home every three months or so.

Once the drug was sent in the mail, the customer was stuck with it — even if he or she was no longer taking the medication. This waste was costing Medicare a lot of money. So the Centers for Medicare & Medicaid Services (CMS) decided to take action and create this new rule.

*If you are in a Medicare Part D plan that is sponsored by your current or former employer, some rules about automatic refills may not apply to you. Contact your plan or mail-order pharmacy for additional information about refills.

Changes to Automatic Refill Services Under Medicare Part D Mail-Order Pharmacies in 2014

Part D Mail-Order Pharmacy

If you are a Medicare beneficiary who gets your medications from a Medicare Part D mail-order pharmacy, I have some important information that may affect your services starting in January 2014.

Many mail-order or home delivery pharmacies provide an automatic refill service that will automatically ship your prescription drugs when you are about to run out of medication. For example, if you have a 90-day prescription for a certain medication, the mail-order pharmacy will automatically ship a refill when you have about two weeks of medication left. This service is very convenient, especially if you take several medications, and it has always been one of the main advantages of using a mail-order pharmacy.

Unfortunately, in recent years some prescription drug plans weren’t periodically checking to find out if their customers still wanted or needed their drugs. The automatic refill service was simply put on auto-pilot, so to speak, and would send the medication to the person’s home every three months or so. Once you received that drug in the mail, you were stuck with it whether you still needed it or not.

Since pharmacies are not allowed to restock prescription drugs that are sent by mail, some automatic delivery services were creating a lot of waste and unnecessary additional costs for people with Medicare and the Part D program in general. So the Centers for Medicare & Medicaid Services (CMS) decided to take action.

Starting January 1, 2014, mail-order pharmacies (and retail pharmacies with home delivery service) must get your approval before they will ship or deliver a new prescription or refill. That means that if you normally get refills every three months, you will need to provide your consent every three months for every medication. Even if your doctor calls in a new prescription, you will still need to provide your authorization. The pharmacy will not be able to ship your medication until you confirm you want to get the order.

Depending on your mail-order pharmacy, you may have to go to a website or reply to an email to provide authorization, or the pharmacy may call you on the phone to get your consent. Either way, the pharmacy will need to reach you before shipping every order, so make sure they have your most current phone number or email address. Until someone from the pharmacy reaches you and gets your consent, the pharmacy will not be able to process the order and ship your medication.

Keep in mind that if you place an order for medication yourself — whether by phone, mail, or online — you will not have to provide additional consent when the medication is ready to be shipped. Also note that this new policy won’t affect refill reminder programs at retail pharmacies when you go in person to pick up the medication. It also won’t apply to long-term care pharmacies that give out and deliver prescription drugs.

If you are currently using a Medicare Part D mail-order pharmacy, you should be receiving a notice by mail or email regarding this change in service. The notice should provide information that is specific to your plan and your pharmacy. If you don’t receive a notice by the first week of January, you should contact the mail-order pharmacy to confirm that your correct contact information is on file.

Caution: Stay away from Medicare Part D plans that have received sanctions from CMS

MH900349511This past week, I had to create a letter regarding a Medicare Part D plan that has been sanctioned by the Centers for Medicare & Medicaid Services (CMS) for conduct that “poses a serious threat to the health and safety of Medicare beneficiaries.”

Government sanctions, or penalties, are just one more reason it is critical for you to review your Part D options every year. If you are in a plan that has received sanctions from CMS, you definitely want to look for a plan that has a high star rating (3 ½ stars or better) to make sure you are going to receive the services you pay for and deserve.

SmartD Rx, a new Part D plan from the Smart Insurance Company, is one plan that is not currently accepting enrollments due to CMS sanction action (I guess the company is not so smart). Here is just part of the letter from CMS to Smart Insurance Company regarding its SmartD Rx plan:

The Centers for Medicare & Medicaid Services (CMS) hereby informs Smart Insurance Company (Smart) of its determination to immediately impose intermediate sanctions…

These intermediate sanctions will consist of the suspension of the enrollment of Medicare beneficiaries…and the suspension of all marketing activities to Medicare beneficiaries. CMS is imposing these intermediate sanctions immediately, effective April 23, 2013…because it has determined that Smart’s conduct poses a serious threat to the health and safety of Medicare beneficiaries.

In its short tenure as a Part D sponsor, Smart has experienced widespread failures in numerous important operational areas including:

• Smart inappropriately rejected drug claims at the point of sale (i.e., pharmacy counter);

• Smart failed to properly process coverage determinations (i.e., requests for drug coverage or payment and reimbursement);

• Smart denied enrollees the chance to appeal rejected claims and failed to ensure that denied coverage determinations were reviewed by an independent third party; and

• Smart failed to process enrollment and disenrollment requests, or failed to properly process enrollment transactions.

As a result of Smart’s noncompliance, its enrollees have experienced delays or denials in receiving prescription drug coverage and increased out-of-pocket costs.

CVS Caremark’s SilverScript is another Part D plan that received sanctions from CMS in 2013. In its letter to the SilverScript Insurance Company—a subsidiary of CVS Caremark – CMS wrote:

Since January 1, 2013, SSIC has experienced widespread data system failures that have directly led to extensive violations of the Part D program’s requirements regarding enrollment processing, call center operation, and claims processing. These failures have created disruptions in tens of thousands of Medicare beneficiaries’ access to prescription medications.

 From January 1 through January 14, 2013, CMS received 2,340 complaints about SSIC’s Part D operations. CMS has received complaints about SSIC at a rate four times greater than the rate of complaints received about all other Part D sponsors combined during the same period.

Other Medicare plan sponsors that have been sanctioned by CMS in the past include HealthNet,  Arcadian, and Universal American (all 2010), and Universal Health Care Insurance Company (2013). You can go to the Part C and Part D Enforcement Actions page on the CMS website for a complete list of plans that have received sanctions and other enforcement actions or had sanctions lifted.

How to get out of a bad Medicare plan

If you are enrolled in a plan that has been sanctioned, and you have personally been affected by your plan’s poor performance, you may be able to get out and switch plans outside of the Open Enrollment period. Your chance to switch is determined by CMS on a case-by-case basis, so you’ll need to call Medicare at 1 800 MEDICARE (1 800 633-4227), 24 hours a day, 7 days a week. TTY: 1 877 486-2048. Or go to this page at for more information.

On Medicare and live in the South? Make sure you’re not taking a high-risk drug.

Seniors in the Southeast are more likely to be prescribed at least one one high-risk medication.

Senior Medicare beneficiaries in the Southeast are more likely to be taking at least one high-risk drug.
Source: NPR (Dany Qato and Amal Trivedi/Alpert Medical School, Brown University)

As I mentioned in my last post, recent findings from Express Scripts show that Medicare providers in New York, New Jersey, and several southern states are less likely to prescribe lower-cost generic drugs then their counterparts in Midwestern states.

Now a new study from the Alpert Medical School at Brown University finds that more than 20 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan are taking at least one high-risk medication. And beneficiaries who live in parts of the South are even more apt to be prescribed high-risk medications. In fact, in many parts of the South – especially the Southeast – more than one-third of seniors are taking drugs that, according to Medicare guidelines, are considered high risk for people age 65 and older.

For example, more than 38 percent of Medicare Advantage enrollees in Albany, Georgia, were prescribed at least one risky drug, compared to 10 percent in Mason City, Iowa, the area with the lowest rate. Beneficiaries prescribed risky drugs were also more likely to be poor, white, and female.

So why are Southerners more likely to be prescribed risky meds? According to the authors of the study, it could be that patients are asking their doctors for them. Or it could be that doctors in these regions are more apt to stick with old prescribing habits. Neither one of these reasons is a valid excuse.

Why are some drugs classifed as risky?

Certain medications are associated with a high risk of side effects and drug toxicity in the senior population, and pose a concern for patient safety. Since 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage plans to report prescribing rates of high-risk medications.

Many drugs are classified as risky because they stay in the body longer, increasing the risk of falls and fractures. Others are classified as drugs to be avoided in people 65 years or older because they are simply not effective enough to be used on a regular basis.

Risky drugs for seniors include amphetamines, barbiturates, muscle relaxants, and narcotics. Old-style sedating antihistamines and medications for depression and anxiety (like long-acting diazepam or Valium®) are also risky, as they can cause sleep apnea or cardiac arrest.

What drugs should be avoided?

The Centers for Medicare & Medicaid Services (CMS) has published a list of high-risk medications to be avoided in patients 65 years and older. Doctors should have this information, but patients and caregivers also need to be aware of this list. The authors of the study — a pharmacist and a medical doctor — suggest that people talk with their doctors about risky medications and make an appointment with their pharmacist to review all their medications to find out if any should be stopped or replaced with a less risky drug.

You should also check the star ratings of your Medicare plan (Part D or MA-PD) if you have prescription drug coverage. CMS awards lower star ratings to Medicare plans if a certain percentage of the plan’s members age 65 and older receive a medication that puts the patient at high risk for an adverse drug-related event, such as a fall or cardiac event. When reviewing Medicare plans, you should ask how the plan scored under “Drug pricing and patient safety.” If you live in the South and your plan has a low star rating in this category, you should definitely be on the alert for prescriptions for high-risk medications.

Read the Fine Print Before Getting Locked Into a Restricted Network Part D Plan

Don't get locked into a Part D plan with a restricted pharmacy network unless it's right for you.

Don’t get locked into a Part D plan with a restricted pharmacy network unless it’s right for you.

As I’ve mentioned several times before, Medicare beneficiaries should always read the fine print and watch out for the terms “preferred network” or “restricted network” when choosing a Part D prescription drug plan (PDP).

Restricted network pharmacy plans encourage members to use national pharmacy chains (such as CVS or Walgreens), which are called preferred network pharmacies. These preferred pharmacies offer covered drugs to plan members at lower out-of-pocket costs than what the member would pay at a non-preferred network pharmacy. A non-preferred network pharmacy, on the other hand, is often the small community pharmacy in your town.

Many of the largest Part D plans have restricted networks, including Humana Walmart-Preferred Rx Plan, Aetna CVS/pharmacy PDP, First Health Value Plus PDP, Rite Aid EnvisionRx Plus, AARP Medicare Rx Preferred, and CVS Caremark Plus. Beneficiaries are attracted to these plans because of the low premiums and copays.

In its 2014 Call Letter, the Centers for Medicare & Medicaid Services (CMS) remind plan sponsors that beneficiary communications regarding preferred networks must be “clear and unambiguous.” In addition, CMS reminds Part D plans that the plans can never–under no circumstances–require beneficiaries who get Extra Help from Medicare and qualify for low-income status (LIS) to use a preferred network pharmacy in order to get their LIS copays.

According to groups like the National Community Pharmacists Association and the Indo-American Pharmaceutical Society, many Medicare beneficiaries are confused by Part D marketing activities that led them to sign up for a “preferred network” plan, only to later find out that the closest pharmacy in the preferred network is 20 miles from their home.

This week, the IAPS posted a sample letter to CMS on its website, and asked that every independent pharmacy owner cut and paste the letter and send it to CMS. Here is a portion of that letter:

I am writing in response to the release by CMS of the Medicare Part D draft Call Letter for 2014. I applaud CMS for addressing certain issues in the Call Letter that have concerned independent community pharmacies and our patients for many years. As an independent community pharmacist, I wish to voice my support for the following provisions that focus on eliminating abusive practices by Part D pharmacy benefit managers (PBM’s) that have disadvantaged patients and independent community pharmacies. I respectfully ask that CMS include these provisions in the agency’s final Call Letter for 2014:

Preferred Pharmacy Networks: We support the fact that CMS addresses some of the improprieties regarding so-called preferred Part D pharmacy networks. My pharmacy is not offered the chance to participate in the vast majority of these networks, which negatively impacts many of my patients who are forced to pay higher co-pays to continue to fill prescriptions at their pharmacy of choice. Plans should be required to offer any pharmacy willing to accept a plan’s terms and conditions the chance to participate in the preferred network per statute (42 U.S.C. § 1395w-104(b)(1)(A)).

In addition, CMS hits the nail on the head when it says that some of these networks require pharmacy “pay to play” in these networks. Where do these reverse pharmacy payments to the plans go? To the beneficiary? To Medicare? Or to the bottom line of the plans? Why should I have to pay a plan to serve my patients?

In addition, many of my patients are confused by these preferred pharmacy networks’ marketing activities. Because of the marketing, patients may believe that they can use any pharmacy in a “preferred” plan and get lower prescription co-pays. Patients may only learn that this is not the case when they come to my pharmacy, and then have to drive long distances to a remote preferred pharmacy in the network to get the lower co-pays.

Finally, there is evidence from the Part D plan finder tool that these preferred networks are charging beneficiaries higher prices (or the same price) for medications than they can obtain at non-preferred pharmacies like mine. It is not clear to me why a pharmacy would be designated as preferred if they are not lowering prescription prices for beneficiaries. In fact, if a my pharmacy is being paid less for the medications than a preferred pharmacy, and the beneficiary is paying more in co-pays at my pharmacy, how can it be that Medicare is actually saving money?

Dear Medicare, We’re not Dead Yet

In Monty Python’s Spamalot, there is a scene with Robin and Lance and a supposed dead man who suddenly rises from a cart singing, “I am not dead yet; No need to go to bed; No need to call the doctor; Cause I’m not yet dead.”

Arnold Ross of New York also sang this song—although not to an audience, but to Medicare. Unfortunately, the people at the Centers for Medicare & Medicaid Services apparently had their ears plugged.

According to this report I came across on Eyewitness News, ever since Arnold’s wife passed away in July, Medicare has declared Arnold dead. “They said I’m deceased. I was dead in their computers,” he tells the reporter. “Look at me, do I look dead?” he said.

Weeks after his wife’s death, Medicare sent Arnold a condolence letter for his own death. Medicare also stopped paying his doctor bills. Arnold says he made many calls to Medicare, but nothing was ever resolved. Eyewitness News made one call and the problem was resolved in a few hours.

Medicare said the initial confusion happened because Arnold and his wife’s Medicare numbers were very similar (in other words, a computer error). They apologized to him for the problem, but couldn’t explain why it took so long to pay attention to his pleas and get it fixed.

A few years back I ran into a similar problem with Medicare — they had accidentally attempted to enroll people into a Medicare Part D plan even though these people had passed away. (Imagine getting a letter thanking your late spouse for joining a Medicare plan.) I had to write a letter to their loved ones expressing condolences for this error.

Unfortunately, because Medicare relies on enormous computer systems to operate, mistakes do happen often. But there was no excuse for the real people at Medicare to ignore Arnold’s calls when their computer system made an error. Talk about Medicare fraud, waste, and ABUSE. If I were in charge, a lot of people would be fired right now for their incompetence.

A question for Medicare: Why must a major Part D program depend on little ol’ me to save it from termination?

Medicare Part D worldIn my last two posts, I talked about how difficult it can be to convince Medicare beneficiaries to take advantage of the Medicare Medication Therapy Management program. One of the problems is that the Centers for Medicare & Medicaid Services (CMS) puts the responsibility on Part D sponsors to get members to opt into the free program. That means prescription drug plan employee peons like me have to write letters or make phone calls to persuade (in other words, beg) eligible plan members to participate in the program.

This week I am faced with a similar situation that involves convincing people to follow their doctors’ orders.  I must write a compelling letter to entice members who are not taking their medications properly to speak with a pharmacist. These members may be skipping pills, forgetting to take their medication, delaying their refills, or doing something else that is causing a gap in therapy (also called nonadherence). If members ignore this letter and don’t take their medication as directed, their Part D plan could be terminated.

Honestly, it sort of feels like the world is on my shoulders.

It’s all in the Medicare stars

To make a long story short, it all has to do with the Medicare star ratings.

CMS uses a star rating system as a guide to help beneficiaries compare the quality of private health plans in the Medicare Part D and Medicare Advantage (Part C) programs. These ratings measure everything from customer service issues such as call wait times to clinical issues such as adherence rates for members taking diabetes and hypertension medications. Based on these measurements, a plan’s overall star rating can range from 1 (poor) to 5 (excellent) stars.

Starting in 2015, CMS can cancel the contracts of Part D and Part C sponsors that fail to receive at least a 3-star (average) rating for 3 years in a row. Potential termination is a great “incentive” for Part C and Part D plans to deliver better care and value. The problem is that not all ratings are created equal: In 2012, clinical measures, such as adherence rates, were weighted three times heavier than other measures.

Many Part D plans received low star ratings in 2012 – even the plan I work for, which got a 5-star rating in 2011, dropped to 4 stars in 2012.  Many of the lower ratings were not due to poor customer service or low member satisfaction, but due to poor medication adherence rates. In other words, because many people are not following doctors’ orders and taking their medication the right way, Part D plans are getting lower star ratings. If these low medication adherence rates do not improve over the next two years, these Part D plans could be shut down by CMS.

CMS: Why is the burden on Part D plan sponsors?

Once again, I ask CMS why all the responsibility is placed on the shoulders of the Part D plan.

Although some plans do have very effective medication management tools in place—such as pharmacist outreach calls—it can be difficult and expensive for plans to ensure their members are following doctor’s orders and taking their drugs as prescribed. Plus, how do strangers at a Part D plan convince people who are not following their doctors’ orders to listen to them? If a doctor can’t make their patients take their medications as prescribed, what chance do I have?

CMS, I really hope you can give me an answer. Because right now, if I can’t convince a few thousand people to get back on track with their medications within the next few months, a large Part D program with a major health plan may soon be getting the boot from you. How wrong is that?

Do Medicare cover Viagra for erectile dysfunction? No it do not. (But sometimes it get screwed anyway.)

Medicare Part D gets screwedOne of the ways I stay on the top of the Medicare industry is by using Google Alerts to monitor the Internet for information about Medicare benefits and regulations. Each day I receive about three or four email updates from Google Alerts, which include links to news articles, blog posts, and miscellaneous Web content.

Although the news articles and blogs are always legitimate, the links under the miscellaneous Web category are almost always spam, with such gramatically-incorrect headlines as “Do medicare cover viagra?” or “Get you cialis with Medicare.” Inevitably, the links take me to some article or advertisement that has nothing to do with either erectile dysfunction (ED) or Medicare.

Just in case anyone is still falling for this spam, Medicare does not cover ED drugs – for the most part.

According to P.L. No. 109-91, section 103, amended section 1860D-2(e)(2)(A) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Medicare Part D program does not cover ED drugs “when used for the treatment of sexual or erectile dysfunction.”  But here’s the catch (of course there’s a catch; we’re talking about Medicare): ED drugs such as Cialis®, Viagra®, and Levitra® are covered by Part D when prescribed for medically accepted indications other than sexual or erectile dysfunction (such as pulmonary hypertension).

Medicare has been screwed to the tune of $3 million

According to a March 2011 report from the Department of Health and Human Services Office of Inspector General (OIG), of approximately $133 billion in gross drug costs for the years 2007 and 2008, Medicare covered more than $3 million in drug costs for ED drugs approved for the treatment of sexual or erectile dysfunction. Part D should not have covered these drugs.

Based on the findings of the study, titled “Review of Erectile Dysfunction Drugs in the Medicare Part D Program,” the OIG recommended the Centers for Medicare & Medicaid Services (CMS) maintain a comprehensive list of ED drugs that have been approved by the FDA for the treatment of sexual or erectile dysfunction. The OIG also recommended CMS distribute this list to all Medicare Part D plan sponsors.

Although this news is two years old, so far I have yet to see this comprehensive list of ED drugs. I also haven’t seen any more reports of Medicare mistakenly covering these drugs. Hopefully this means that CMS has its act together despite the lack of a list. But then again, maybe these spammers who keep cropping up on my Google Alerts know something we don’t know.

Oops: Medicare Plan Mistakes Happen — More Often Than You’d Like to Think

Medicare errors happen

Medicare plans do make mistakes from time to time.

Last week I received a Google Alert about CVS Caremark Corp. and the Tufts Health Plan Medicare Preferred Plan. It seems that CVS mistakenly sent letters with information about the medical conditions of people in the Tufts Medicare plan to about 3,500 people enrolled in another plan. The letters also included information about some of the medications the Tufts Medicare members were taking.

According to The Boston Globe, CVS Caremark said a “programming error” was the cause of this information breach. The company said the information went to the wrong addresses in January and February, and included another member’s name, the name of a prescribed medication, and what the medication is used for. Fortunately, the letters did not include financial account numbers. CVS Caremark also said it doesn’t believe the information was used improperly.

“We are writing today to apologize for a system error”

For the past six years or so, I have been writing apology letters to members of Medco Medicare Prescription Plan for all kinds of system errors. Although I can only recall one time when the company sent information to the wrong addresses, I have written apology letters for many other kinds of mistakes. For example, we’ve had to apologize for inadvertently:

  • Failing to send a communication required by Medicare on time
  • Overcharging for  medications
  • Rejecting drug claims
  • Sending members the wrong plan materials

Medicare is a moving target

Thanks to the constant guideline changes and the enormous number of complex rules and regulations in the Medicare program, every Medicare plan is like a moving target; a constant work in progress. And now with all the changes under healthcare reform—such as the Coverage Gap Discount Program—that target is moving at the speed of light.

I can’t even tell you how many employees we have who are responsible for constantly updating our computers and databases to accommodate these changes—not because I literally can’t tell you, but because I simply don’t know. If I had to guess, I’d say a few hundred or more.

Medicare plan employees are sincerely sorry for these errors

So yes, system errors happen quite often, simply because it’s impossible for humans to keep up with all the changes coming at us from the Affordable Care Act and the Centers for Medicare & Medicaid Services. We try our hardest to prevent these mistakes from occurring, but sometimes a piece of computer code falls through the cracks. When that happens, we send every affected member an apology letter right away. It may not seem like much, but I want to ensure you that our apologies are sincere.

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