Combating fraud and abuse in the Medicare Prescription Drug Program

By Jonathan Blum, CMS Principal Deputy Administrator

The Centers for Medicare & Medicaid Services (CMS) takes prescription drug abuse very seriously and actively works to detect and prevent fraud and abuse in order to protect the Medicare program, its beneficiaries, and taxpayers.

The Medicare Part D prescription drug benefit provides prescription drug coverage to more than 39 million seniors. CMS strives to ensure that beneficiaries have the medications they need while at the same time is being vigilant to safeguard the program from inappropriate use. 

A centerpiece of our strategy to combat fraud and abuse in Medicare Part D is the identification of Part D enrollees who have potential opioid or acetaminophen overutilization issues that may present a threat to patient safety. Overutilization of opioids or acetaminophen products can result in serious adverse events or death. The Medicare Part D Overutilization Monitoring System was implemented in 2013 to help CMS ensure that Part D plan sponsors are meeting CMS requirements to establish reasonable and appropriate drug utilization management programs to prevent overutilization of these medications.  Comparing recent data with 2011 Part D data that pre-dates the implementation of the monitoring system shows that there has been a substantial reduction in the number of opioid and acetaminophen overutilizers in Medicare Part D.  In 2011, more than 172,000 Part D enrollees were identified as meeting CMS criteria for potential opioid or acetaminophen overutilization.  Between January and June 2013, the number of Part D enrollees with potential opioid or acetaminophen issues dropped to approximately 35,600 – a rate that would represent a reduction of nearly 60 percent if maintained throughout 2013.  

CMS also released a proposed rule today that seeks to employ new tools when problematic prescribers and pharmacies are identified. Some of the proposed key fraud and abuse provisions include:

  • ·       Requiring prescribers of Part D drugs to enroll in Medicare and revocation such enrollment in cases of abusive prescribing practices and patterns;
  • ·       Allowing CMS to request and collect information directly from pharmacy benefit managers, pharmacies and other entities that contract with Part D sponsors to better detect fraud; and
  • ·       Improving CMS’ ability to collect identified Medicare overpayments from MA plans and Part D sponsors.

Combined with our ongoing efforts, the fraud and abuse provisions in the proposed rule will ensure that Medicare beneficiaries have access to affordable prescription drugs while making certain that plans provide value to Medicare and taxpayers.

For more information about our efforts to combat fraud, waste and abuse in Medicare Part D, please visit: http://www.cms.gov/Newsroom/Newsroom-Center.html.

To read the proposed rule, please see: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1. The proposed rule will be published in the Federal Register on January 10, 2014.  CMS will accept comments on the proposed rule until March 7, 2014. 

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