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Aetna fined $1 million for Medicare Part D in-network mishap

Payer wrongly identifying in-network pharmacies, has 60 days to appeal the penalty

The Centers for Medicare & Medicaid Services (CMS) has fined Aetna $1 million for the insurer's recent mishap of wrongly identifying 6,887 pharmacies as being in its network.

In an April 2 letter to the Hartford, Connecticut-based insurer, CMS Director of Medicare Parts C and D Oversight and Enforcement Group Gerard Mulcahy wrote, "The confusion created by errors in Aetna's pharmacy network directory on their website led to disruption in the marketplace."

CMS became aware of the debacle back in February. It stemmed from an issue with Aetna's CMS Medicare Plan Finder. After Jan. 1, many Aetna enrollees learned that their usual pharmacies were no longer in their plan's network. As a result, members were then forced to either pay cash or leave the pharmacy without their prescription, Mulcachy wrote.

At CMS' urging, Aetna gave more than 400,000 Medicare beneficiaries until the end of the February to either find other pharmacies or switch plans. At the time, Aetna said it was monitoring claims that were filed incorrectly to ensure members pay the in-network costs for their particular prescriptions.

For Medicare beneficiaries, a mix-up like this can pose serious consequences. These members rely on vital information--from an insurer's website, pharmacy tool and customer service department--to make important decisions regarding their insurance and prescription drug options, according to the letter.

Aetna's complaint rates for Medicare Part D issues were five times greater than the complaint rate for all Part D parent organizations, Mulcahy added. Aetna's 3,767 complaints accounted for 33 percent of all complaints received by CMS. What's more, 73 percent of these complaints related to marketing issues that misled beneficiaries about in-network pharmacy coverage.

Aetna can request a hearing to appeal the penalty and must do so by June 2. However, if Aetna does not request an appeal, the insurer will need to dish out the fine.

This is not the first time Aetna faces harsh scrutiny for misleading members. Back in 2010, CMS imposed an intermediate sanction to stop the insurer from marketing to or enrolling new Part D beneficiaries in its plans after learning about problems with Aetna's administration of its Part D drug benefit, FierceHealthPayer previously reported.

For more:
- here's the letter (.pdf)

Related Articles:
Updated: Aetna wrongly identifies Part D in-network pharmacies
CMS to sanction Aetna for Part D drug mishaps
Report: Out-of-pocket costs too high