This is the first in a series of articles relating to the OIG reports.
Recently the Office of the Medicare Inspector General (OIG) issued two reports related to the Medicare D program; Ensuring Integrity of the Medicare Part D Program and Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D. These reports were the result of the OIG’s investigations, audits, and analyses, undertaken since the Part D program’s inception. The reports were highly critical of the compliance efforts of the Centers for Medicare and Medicaid Services (CMS) and the Medicare Part D plan sponsors (Plan Sponsors). The reports serve as a harbinger of the actions likely to be taken by CMS, Pharmacy Benefit Managers (PBMs) and Plan Sponsors, based on the OIG’s criticism and recommendations.
Examples of the OIG’s recommendations include:
- Compelling CMS to require Plan Sponsors to report all potential fraud and abuse to CMS
- Require Plan Sponsors to report data on the inquiries and corrective actions they take in response to fraud and abuse
- Expand drug utilization review programs to include additional drugs susceptible to fraud, waste, and abuse
- Implement an edit to reject prescriptions written by excluded providers
- Exclude Schedule II drug refills when calculating final payments to plan sponsors at the end of each year
The OIG also recommended the use of data mining, by CMS and Plan Sponsors, to identify questionable billing practices and potential fraud by pharmacies. The metrics identified by the OIG as likely indicia of fraud and abuse included:
- The average number of prescriptions per beneficiary
- Percentage of prescriptions for commonly abused opioids
- The average number of prescribers for commonly abused opioids per beneficiary who received opioids
- The average number of types of drugs per beneficiary
- Percentage of beneficiaries with an excessive supply of a drug
It is likely that Plan Sponsors will be influencing their respective PBMs to adopt some, if not all, of the OIG’s recommendations. PBMs will undoubtedly be compelled to launch new waves of audits directed at pharmacies, particularly those with prescription histories that reflect the questionable patterns identified by the OIG.
Frier Levitt has the knowledge, experience and practice focus necessary to assist pharmacy clients in developing compliant practices defending pharmacies facing PBM audits. If you have questions about how these reports will impact your pharmacy, contact Frier Levitt today.
