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A Rap Sheet For Medicare’s Prescription Drug Program

An update on the new events since we published our Prescriber Checkup investigation.

A lot has happened since our investigation in May showed that Medicare wasn’t watching out for dangerous or fraudulent prescribing by doctors and others in its popular prescription drug program. In the past two weeks:

The inspector general has found fault with Part D’s oversight almost since its inception. Below are summaries of its most recent reports, as well as significant earlier ones.

Illegitimate prescriptions

Last Monday, the inspector general reported that Medicare paid for 417,000 prescriptions purportedly written by massage therapists, athletic trainers, interpreters and others who aren’t allowed to prescribe drugs. While just a small fraction of total drug spending in the program, it raises questions about how closely Medicare officials are tracking the validity of prescriptions or questioning those that appear suspicious.

High-prescribing doctors

On June 20, the inspector general cited more than 700 general-care physicians who wrote prescriptions for elderly and disabled patients in highly questionable and potentially harmful ways. They were very extreme outliers in one of several areas: prescriptions per patient, brand name drugs, painkillers and other addictive drugs or the number of pharmacies that dispensed their orders.

Scant Analysis

In January, the inspector general found that Medicare’s fraud integrity contractor did little to proactively analyze prescribing data for indications of fraud and abuse. Between April 2010 and March 2011, the contractor only referred 19 cases to law enforcement based on its proactive analysis of Part D data.

Questionable Pharmacy Billing

In May 2012, the inspector general identified more than 2,600 pharmacies with questionable billing practices. “Little information is currently available about Part D billing,” the report said. “There are no data about how pharmacies typically bill Part D, or about questionable billing. Identifying these data is an important first step in detecting potential fraud, waste, and abuse.”

Banned Prescribers

In December 2011, the inspector general identified $15.1 million in drugs paid by Medicare Part D from 2006 to 2008 that apparently had been prescribed by health professionals banned from the Medicare program. The report cited “inadequate internal controls” at the Centers for Medicare and Medicaid Services (CMS).

Inappropriate Drugs

In May 2011, the inspector general found that Medicare Part D had paid for antipsychotic prescriptions for elderly nursing home residents for uses not approved by the U.S. Food and Drug Administration. The drugs specifically carry a warning that they can increase the risk of death in patients with dementia. The inspector general recommended that Medicare require prescriptions to carry a diagnosis code to help flag drugs given for inappropriate reasons, but Medicare said no.

Invalid Prescribers

In June 2010, the inspector general found that $1.2 billion in drugs paid by Medicare in 2007 lacked valid identification for those who prescribed the drugs. “Without valid and accurate prescriber identifiers, CMS and its contractors have difficulty performing oversight functions, such as verifying the prescriber's licensing information, determining whether the prescriber has been the subject of disciplinary actions for inappropriate activities, or tracking potential overprescribing issues,” an inspector general official told Congress.

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