Part D Fraud Enforcement Commences

Part D prescription fraud is the latest target of efforts to continue identifying, preventing, and recovering fraud, the Centers for Medicare & Medicaid Service (CMS) announced Dec. 13. CMS is asking Part D prescription drug plan sponsors to stop drug misuse and fraud, especially with pain killers like OxyContin, which are the fifth most filled class of drugs in Medicare totaling $3.9 billion.

The General Accounting Office (GAO) identified the problems, which prompted CMS to convey the following messages, plus others, to plan sponsors:

Investigate and Stop Payment for Suspect Claims

  • Medicare’s requirement that pharmacies receive prompt payment for prescription drugs does not prevent sponsors from investigating suspect claims and withholding payment for fraudulent claims.
  • When a sponsor suspects fraud with respect to a particular claim, payment need not be made until the claim has been investigated further to determine that it is not fraudulent.

Use Tools to Help Manage Proper Drugs Use

  • Prior authorization requirements are a common tool employed by Part D sponsors to ensure appropriate utilization and coverage under the Medicare Part D program.
  • Part D sponsors may implement reasonable prior authorization requirements for drugs, such as opioids, that are more susceptible to abuse and diversion.

Limit Prescriptions to 30-Day Doses

  • The guidance encourages plan sponsors to work with doctors to prescribe less than 30 days supplies for drugs that are more susceptible to abuse or diversion.

The Obama administration is keen to continue its success in recovering $5.6 billion in fraudulent payments in 2011, which it says is a 167 percent increase from 2008.

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