July 29, 2015
Pharmacy Group Urges Caution in Crackdown on
Medicare Part D Fraud

Washington, D.C.—With a new report showing that 1,432 pharmacies had questionable billing for opioid medications, the call is growing for a crackdown on Medicare Part D fraud.

A key pharmacy group is urging caution, however, out of concern that tightening restrictions too much could deny legitimate patients access to critical medications.

B. Douglas Hoey, RPh, MBA, CEO of the National Community Pharmacists Association (NCPA), recently submitted testimony to the subcommittee on Oversight and Investigations of the Committee on Energy and Commerce. “While NCPA remains supportive of efforts to prevent and reduce fraud, waste and abuse within the Medicare Part D program,” Hooey testified, “they must be delicately balanced with ensuring appropriate patient access to vitally important medications.”

According to a report from the Office of Inspector General (OIG) for the Department of Health and Human Services, 1,432 pharmacies had questionable billings for opioid medications, and average billings were higher than average in some cities for specific drugs.

“A total of 1,432 retail pharmacies billed extremely high amounts for at least one of the five measures we reviewed,” according to the OIG report. “A total of 292 pharmacies billed extremely high amounts for multiple measures. Specifically, 283 pharmacies did so for 2 measures, and 9 did so for 3 measures.”

Representing 2% of pharmacies nationwide, the 1,432 with questionable practices billed $2.3 billion to Part D in 2014, according to the report. The OIG said the pharmacies were more likely to be independently owned and to be located in the New York, Miami, Los Angeles, and Detroit metropolitan areas.

The recent hearing was held, according to the subcommittee chairman, Rep. Tim Murphy (R-PA), because “Medicare Part D is the fastest growing component of the Medicare program, providing approximately 39 million beneficiaries with supplemental prescription drug coverage. Given this rapid growth, Medicare Part D has been a prime target for fraud and abuse.”

Included in the NCPA’s comments were the following recommendations:

• Part D plan sponsors should be required to report potential fraud and abuse or preventative steps taken as recommended by the OIG, because, under the current voluntary reporting system, fewer than 50% of plan sponsors report the information.
• Current drug utilization review programs, such as for controlled substances, should be continued but reviews shouldn’t be expanded to additional drug therapies because it could be unduly burdensome and affect timely care for patients.
• Legitimate patient care circumstances should be taken into consideration with any examination of “questionable pharmacy billing practices,” e.g., a community pharmacy serving a large number of oncology or pain-management practices may dispense more controlled substances than other pharmacies.
• Beneficiary protections should be included in any “lock-in” proposal to restrict certain beneficiaries to a specific pharmacy or prescriber, such as the ability to choose both the in-network prescriber and pharmacy.

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