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House subcommittee grills OIG, CMS on Part D fraud and abuse

Representatives question CMS on previous OIG fraud prevention recommendations that have gone unimplemented

Highlighting two recent reports by the Office of Inspector General (OIG) that reveal missed fraud prevention opportunities by the Centers for Medicare & Medicaid Services (CMS), members of the Subcommittee on Oversight and Investigations grilled leaders of the OIG and CMS at a hearing Tuesday, looking for ways to detect and prevent Part D fraud, waste and abuse.

Members of the subcommittee harped on the high volume of opioid prescribing through Medicare Part D that has led to an increase in opioid addiction throughout the country. OIG reports show that spending on commonly abused opioids has grown 156 percent within the last nine years, reaching $3.9 billion in 2014. The total number of beneficiaries receiving those drugs grew 98 percent, compared to 68 percent for all other drugs. In the recent national fraud takedown, 44 of the 243 individuals arrested were involved in Part D fraud schemes, many of which involved opioid prescriptions.

In particular, the subcommittee, led by Rep. Tim Murphy (R-Pa.), sought to find out why CMS had not implemented nine recommendations outlined by the OIG in previous reports. For more than two hours, representatives questioned Shantanu Agrawal, M.D., deputy administrator and director for the Center for Program Integrity at CMS, and Ann Maxwell, assistant inspector general of evaluation and inspections at the OIG, about how CMS oversees Part D claims and why the program is vulnerable to fraud and abuse.

Agrawal pointed to some specific measures CMS has already implemented, including a final rule released last year that requires Part D prescribers to be enrolled in Medicare and allows the agency to revoke Medicare enrollment for those with abusive prescribing habits. Agarwal said that CMS is in the process of enrolling more than 400,000 prescribers by January 2016. Part D prescriptions that do not meet these requirements will be denied by Medicare by June 2016.

Much of the hearing also revolved around reporting requirements and oversight for Part D plan sponsors. Currently sponsors are allowed to voluntarily report fraud and abused data to CMS, however, as of 2014, only 35 percent submitted reports. Maxwell said that without mandatory reporting, CMS and the OIG lack the data to better understand how plan sponsors are combating fraud and abuse.  

"We don't have the visibility to hold them accountable," she said of the plan sponsors.

Agarwal said that plan sponsors offer the first line of defense for fraud and abuse, and that CMS has been sharing data and performing drug utilization reviews in an attempt to idenfity potential fraud hotspots. Certain plan sponsors are effective investigating leads provided by CMS, others have "room for improvement," he said. However, he did not indicate fraud reporting should be mandatory, citing hesitancy among sponsors to release that information to competitors. 

Many of the subcommittee members appeared impatient during the hearing, and at times aggressively directing questions toward Agarwal. In particular, Rep. Marsha Blackburn (R-Tenn.) criticized the agency for inefficiencies in preventing fraud, waste and abuse within the Part D system.

"When you are given recommendations, we expect those recommendations to see an action," she said during her opening remarks. "Don't tell me you're overworked, and don't tell me you don't have enough money. When you have a job to do you work until the job is done."

During the hearing, Maxwell also pointed to three specific oversight tools that would improve Part D oversight:

  • Stronger payment controls, particularly those made to doctors excluded from Medicare
  • A "lock-in" program that restricts certain beneficiaries that are identified as overusing opioids to a limited number of pharmacies and prescribers in order to prevent drug diversion
  • Improved processes to recover inappropriate Part D payments

Agarwal said that while CMS generally agrees with the recommendations set forth by the OIG, each requires a multi-faceted approach, which, in turn, requires time to implement. He specifically noted that President Barack Obama has included funding for lock-in programs in the 2016 budget and that CMS would look to implement that approach if that fundong is finalized.

For more:
- here's the homepage for the subcommittee hearing

Related Articles:
OIG reports revisit questionable billing and fraud within Medicare Part D
Historic Medicare fraud takedown: Feds charge 243 people with $712M in false billing
OIG to CMS: Ramp up Part D anti-fraud oversight
New Medicare rules target Part D fraud and abuse
Medicare Part D fraud reporting and cost trends