New Medicare rules target Part D fraud and abuse


The Centers for Medicare & Medicaid Services issued a final rule last week to screen drug prescribers more carefully, release more Part D data and get direct access to sponsors' downstream entities. These changes are expected to save more than $1.6 billion for Medicare through 2024.

"The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D Program so that we can continue to protect beneficiaries and taxpayers," said CMS Administrator Marilyn Tavenner in an announcement.

The new rule requires Part D drug prescribers to be enrolled in Medicare or have a valid record of opting out of the program for their prescriptions to qualify for benefit payment. As of June 1, 2105, Medicare contractors must deny payment for pharmacy claims if they don't have the ID of a valid prescriber, Bloomberg Businessweek reported.

This change may help fix a longstanding vulnerability. Last year, the Office of Inspector General identified 7,679 prescriptions for often-abused drugs, such as oxycodone, written for Medicare patients by people without program prescribing authority, including massage therapists, dieticians, sports trainers and veterinarians, Bloomberg noted.

Further, CMS may now revoke Medicare enrollment if a provider prescribes abusively, threatens the health and safety of beneficiaries, or otherwise fails to meet program requirements, the announcement stated. CMS will also be able to cancel enrollment if a provider's Drug Enforcement Administration certificate of registration is suspended or revoked, or if a state or other licensing body suspends the provider's prescribing ability.

To expand public access to healthcare data, the rule also allows the release of unencrypted prescriber, plan and pharmacy identifiers in prescription drug event records. This change is likely to incite provider pushback, The Hill noted, consistent with what happened after CMS released 2012 data on Medicare payments to individual physicians.

Further, the final rule allows the federal government to collect information directly from pharmacy benefit managers, pharmacies and other organizations that contract with sponsors to administer Part D, according to a CMS fact sheet. This provision may improve the efficiency of governmental fraud investigations by eliminating the need for CMS to go through middlemen to get required information.

For more:
- here's the final rule (.pdf)
- read the CMS announcement and fact sheet

- see the Bloomberg Businessweek article
- here's The Hill article

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