CMS Addressing Medicare Drug Fraud, Waste, Abuse
The Government Accountability Office compiled a report to determine practices to promote prescription drug program integrity.
- Because of recent law enforcement actions and the increase in focus in the media highlighting Medicare prescription drug fraud, abuse and waste, the Government Accountability Office (GAO) compiled a report to determine practices to promote prescription drug program integrity.
The GAO’s findings identified 23 practices to aid in the prevention of prescription drug fraud, abuse and waste within the Medicare program. Each of these practices also falls under the three basic categories: prevention, detection and monitoring, and investigation and prosecution.
Currently, the Centers for Medicare & Medicaid Services (CMS) already implement the following practices to aid in the prevention of prescription drug fraud, abuse and waste within the Medicare program.
Prevention
Collaboration: CMS established relationships with a variety of stakeholders to develop programs and strategies to address prescription drug fraud, waste, and abuse.
Education: Outreach & Education Medicare Drug Integrity Contractor (O&E MEDIC), collaborating with CMS Center for Program Integrity, offers a variety of materials and events, and training to Medicare beneficiaries on how to prevent potential fraud.
Prepayment edits: For every prescription, plan sponsors must check a range of information, typically at the point of sale or distribution, such as drug interactions, incorrect amounts, and age or gender contraindications, such as a woman receiving medications prescribed only to men.
Screening: Plan sponsors must verify beneficiaries’ Part D eligibility.
Detection and monitoring
Collaboration: Plan sponsors share information with CMS regarding potentially fraudulent providers or schemes. CMS sends memos to all plan sponsors about new Part D fraud schemes and potentially fraudulent.
Compliance program: Plan sponsors must have effective compliance programs.
Data analysis: Plan sponsors are to have clinical and analytic staff, or contract with an entity that can provide such staff, to monitor and analyze data as part of their compliance programs.
Drug utilization review: Plan sponsors review beneficiaries’ drug utilization patterns to identify potential patient harm and beneficiaries at risk for overutilization, and refer those beneficiaries for case management. CMS also reports quarterly to plan sponsors the names of beneficiaries over-utilizing opioids and certain other drugs through CMS’s Overutilization Monitoring System. Plan sponsors must report to CMS quarterly on how each identified case is addressed.
Education: O&E MEDIC provides training and materials to plan sponsors and others on how to identify potential fraud, waste, and abuse.
Prepayment edits: Plan sponsors provide beneficiaries with an explanation-of-benefits document to review for potential errors that also has a telephone number to report potential fraud.
Investigation and prosecution
Collaboration: CMS hosts quarterly meetings with a variety of stakeholders on prescription drug fraud, waste, and abuse.
Investigations/investigative staff: Plan sponsors are to have staff that can identify potential fraud.
Reporting to law enforcement: CMS encourages plan sponsors to refer potential fraud to law enforcement and/or CMS.
The CMS plans to strengthen four of these practices as well as implement an additional three practices in order to better prevent prescription drug fraud, abuse and waste in the future. The new practices will include a prescription drug monitoring program to assist in detecting potential patterns of prescription drug fraud, waste, and abuse.
