HHS’ OIG Urges CMS To Bolster Oversight of Medicare Part D
CMS needs to do more to protect Medicare Part D against fraud, according to two reports issued Tuesday by the HHS Office of Inspector General, Modern Healthcare reports.
The reports come days after federal officials announced a large number of fraud charges related to the drug benefit program (Schencker, Modern Healthcare, 6/23). Nearly 250 people, including 46 providers, were charged with falsely billing Medicare a total of nearly $712 million. According to Attorney General Loretta Lynch (D), it was the "largest criminal health-care fraud takedown in the history of the Department of Justice" (California Healthline, 6/19).
Questionable Billing Patterns
One report found 1,432 pharmacies with questionable billing patterns in 2014. Such practices, among other things, included:
- High numbers of prescriptions per beneficiary;
- High percentages of prescriptions for commonly misused opioids; and
- Large numbers of beneficiaries with excess supplies of drugs (Ornstein, ProPublica, 6/23).
The report said, "Although some of this billing may be legitimate, all pharmacies that bill extremely high amounts warrant further scrutiny."
In addition, the report identified several cities across the U.S. that had particularly high billings for certain medications in 2014. Such "hotspots" included:
- Los Angeles;
- McAllen, Texas;
- New York City; and
- San Juan, Puerto Rico.
According to the report, the billing patterns in these cities raised questions about the medical necessity of the prescribed drugs.
The report also questioned whether some pharmacies had billed for a certain drug and then dispensed lower-cost generics or over-the-counter medications in their place.
The second report urged CMS to implement more of OIG's recommendations to help protect against fraud and abuse in the Part D program.
According to the report, "In many instances, action has been taken to implement our recommendations and strengthen Part D program integrity. However, more work needs to be done to protect the program from fraud, waste and abuse" (Modern Healthcare, 6/23).
The report recommended requirements for plan sponsors to report to CMS or its Medicare Drug Integrity Contractor all potential cases of fraud and data on inquiries and corrective actions to remedy any fraud or abuse (ProPublica, 6/23).
OIG also recommended that CMS:
- Implement a method to reject prescriptions written by excluded providers;
- Restrict some beneficiaries to a limited number of prescribers;
- Measure the efficacy of plan sponsors' fraud and abuse detection programs; and
- Omit Schedule II drug refills from plans sponsors' final payment calculations.
CMS spokesperson Aaron Albright said the department has taken steps to implement previous OIG recommendations. He noted CMS also has several initiatives in place to bolster Part D oversight.
Albright said, "CMS works diligently with our law enforcement partners to prevent fraud in the first place and to recover payments for wasteful, abusive or fraudulent services." He added, "Since the Part D program began, CMS has taken steps to address [OIG's] recommendations and (has) made progress collecting and analyzing data to proactively identify potential fraud as well as conduct robust oversight of plans" (Modern Healthcare, 6/23).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.