Last week, the House Energy and Commerce Subcommittee on Oversight and Investigations held a hearing on Medicare Part D program integrity, an increasingly hot topic. Members of Congress are especially concerned about, as Energy and Commerce Chairman Fred Upton phrased it, the “startling increase in Medicare Part D spending on commonly abused opioids.” Shantanu Agrawal of the Centers for Medicare and Medicaid Services and Ann Maxwell, Assistant Inspector General, Office of Evaluation and Inspections, Office of Inspector General, U.S. Department of Health and Human Service provided testimony.
Ann Maxwell, speaking on behalf of OIG, stated that her agency has made “stopping Part D fraud a top priority.” In June, the Department of Justice announced an unprecedented nationwide sweep led by the Medicare Fraud Strike Force resulting in charges against 243 individuals for their participation in fraud schemes involving $712 million in false billings. Almost 50 of the defendants were charged with fraud related to Part D. While Maxwell was pleased with the enforcement efforts, she noted that they do not solve the problem of prescription drug fraud.
To this point, she outlined her agency’s recommendations to CMS and Part D plan sponsors that would more proactively identify questionable billings and prevent fraud. While CMS has “made some progress,” Maxwell stated, it must do more to protect the Medicare Part D program. (View Maxwell’s testimony, pages 5-7 for specific recommendations).
Subcommittee Chairman Tim Murphy (R-PA) agreed, noting that CMS has not implemented nine HHS-OIG recommendations to stem Part D fraud. HHS-OIG recently issued two reports, “Ensuring the Integrity of Medicare Part D,” and “Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D,” that summarize their recommendations over the past several years. “[T]hese are commonsense recommendations,” Murphy said. “For example, requiring plan sponsors to report all potential fraud abuse to CMS or the Medicare Drug Integrity Contractor. This recommendation was issued in five different OIG reports. Another important recommendation: implement an edit to reject prescriptions written by providers who have been excluded from the Medicare program.” Members of the committee also honed in on OIG’s recommendation for a beneficiary “lock-in.” OIG found in one investigation, for example, that a “complicit beneficiary” received unnecessary prescriptions, filled them at various pharmacies, and sold the pills to drug-trafficking groups. “This could be addressed by restricting beneficiaries to a limited number of pharmacists or prescribers when warranted.” CMS has stated that it would require legislative authority to implement lock-in restrictions.
“CMS hasn’t taken action to implement these recommendations,” Murphy stated. “Just six weeks ago, one of today’s witnesses, Dr. Agrawal testified before this Subcommittee and said, “holding our feet to the fire is appropriate,” when asked about fraud occurring under CMS’s watch, and that’s precisely what we are here to do today.”
Indeed, during his testimony, Dr. Agrawal agreed that work needed to be done, and that CMS is “committed to working with OIG to address its recommendations.” But he also outlined some of the strides CMS has made, citing his agency’s increased sharing of data with Part D plan sponsors to enhance the detections and prevention of fraud and overutilization of Part D drugs, including opioids.
Agrawal explained CMS’s plans to use the authority granted in the Affordable Care Act to require most prescribers of drugs paid for by Part D to enroll in Medicare. “CMS is actively working to enroll over 400,000 prescribers of Part D drugs by January 2016 and to enforce the requirement that plans deny Part D claims that are written by prescribers who do not meet the necessary requirements by June 2016,” he said. “These prescribers will be subject to the same risk-based screening requirements that have already contributed to the removal of nearly 575,000 provider and supplier enrollments from the Medicare program [and will] “make sure that Part D drugs are prescribed by qualified individuals, and will prevent prescriptions from excluded or already revoked prescribers from being filled.”
Agrawal also noted that efforts to combat should balance the need to ensure that all Medicare beneficiaries are receiving the medications they need.
On the same day as the hearing, CMS announced that its Fraud Prevention System had identified or prevented $820 million in inappropriate payments over the past three years through, including more than $454 million identified in 2014 alone. The “FPS” uses predictive analytics to identify questionable billing patterns in real time. It can also review past patterns that may indicate fraud.