Medicare officials announced this week that they are tearing up their contract with a New York-based company – with 4,100 California clients – that delayed or denied patients access to medications they needed.
Fox Insurance Co. let down its 123,000 enrollees by putting obstacles between patients and costly but life-sustaining medications for cancer and HIV, according to a release by Medicare.
Medicare falls under the supervision of Health and Human Services Secretary Kathleen Sebelius, who has been a vocal critic of Anthem Blue Cross over its move to hike some patient's premiums by 39 percent.
Medicare spokesman Peter Ashkenaz said the Fox contract termination was the first of its kind under Medicare Part D, the program put in place by George W. Bush to ensure prescription drug access to Americans older than 65.
Medicare, a massive government agency, contracts out the day-to-day work of getting those medications to seniors to private, mostly for-profit companies like Fox.
The bulk of the company’s enrollees are from Florida, North Carolina and New York. But 4,100 enrollees are spread throughout California and will get their medications through a different company, according to Medicare. Medicare sent a letter to Fox describing one of its failures to get medications for a patient in need:
Additionally, CMS has concrete evidence that Fox’s non-compliance with required coverage determination timeframes led, in at least one instance, to a significant delay in HIV therapy that could put the patient’s health at serious risk. On February 4, 2010, CMS was copied on a letter from a provider to Fox.
According to the letter, on January 13, 2010, at 2:14 PM, the provider requested via fax that Fox make an expedited determination on a prior authorization for an HIV medication (Atripla). After no determination was received, subsequent requests were made less than 24 hours after the initial request, almost 45 hours after the initial request, and 120 hours after the initial request.
Approval was received via fax from Fox on January 18, 2010 at 3:46 PM, 121 hours and 32 minutes after the initial request was made by the provider. Pursuant to 42 CFR §423.572(a), Fox was required to make its determination on the expedited request no later than 24 hours after receiving the request.
Additionally, pursuant to 42 CFR §423.572(d), Fox was required to forward the enrollee's request to the independent review entity (IRE) under contract with CMS within 24 hours after expiration of the adjudication timeframe and failed to do so.
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