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WellPoint, Inc. Did Not Always Calculate Enrollees' True-Out-Of-Pocket Costs in Accordance With Federal Requirements

WellPoint, Inc. (a Part D drug plan sponsor), did not always calculate ture out-of-pocket (TrOOP) costs in accordance with Federal requirements. For calendar years 2008 and 2009, we estimated that the Federal Government (on behalf of enrollees) overpaid while WellPoint underpaid their respective shares of the drug costs by $2.8 million.

We recommended that WellPoint (1) calculate TrOOP costs in accordance with Federal requirements, (2) enhance communication with other plans to ensure TrOOP balances are transferred properly, (3) implement system edits to ensure each claim is processed according to its plan benefits, and (4) implement system edits to ensure PDE records are adjusted to accurately update TrOOP balances. WellPoint agreed with our findings and described steps it has taken to address our recommendations.

Filed under: Centers for Medicare and Medicaid Services