Data Analysis And The Fight Against Medicare Part D Abuse

By: Louis C. Szura, Esq.
Date: July 15, 2015

The newest battleground for the war against Medicare fraud and abuse – electronic data analysis – is proving fruitful. But, more needs to be done, especially concerning the fraud and abuse of opioid prescriptions through Part D.

Yesterday, CMS announced that, during the 2014 calendar year, its Fraud Prevention System (FPS) “identified or prevented $454 million” in “troublesome billing patterns and outlier claims” throughout Medicare. The FPS identifies those inappropriate payments for follow-up action with a data analysis systems similar to systems used by credit card companies to proactively detect fraud.  Moreover, the FPS seems to be increasing its ability to detect inappropriate payments as it gains information reviewing various forms of fraudulent behavior around the country. A larger dollar amount of inappropriate billings were detected in 2014 than in the previous two years combined ($820 million).

While the FPS is used to identify all types of inappropriate billing, CMS also provided additional detail about its fight against Medicare Part D fraud and abuse of opioids. Coinciding with its FPS announcement, representatives of the Centers for Medicare and Medicaid Services and the HHS Office of Inspector General testified before a U.S. House Committee on the topic of strengthening the program integrity of Medicare Part D to prevent opioid abuse. The testimony focused on the rampant abuse of opioids and what can be done to stop it. As part of their testimony, Ann Maxwell from OIG and Shantanu Agrawal from CMS shared their insight and some alarming statistics about opioid abuse gathered from data analysis:

  • From 2006 to 2014, spending for Part D drugs more than doubled. It increased by 136%, from $51.3 billion to $121.1 billion. Over the same time, spending for commonly abused opioids grew at an even higher rate, from $1.5 billion to $3.9 billion, an increase of 156%.
  • The OIG examined pharmacy billing patterns in 2014 to look for questionable billing that might be an indicator of fraud and identified 1,432 retail pharmacies that had questionable billing in that time period.
In light of the situation, the representatives resolved to increase their efforts to stem the tide of abuse. In addition to their existing powers, they identified additional measures that are going to be taken to fight this growing problem. The pointed out that the President’s proposed 2016 Budget would provide the Secretary of HHS with expanded authority to:

  1. Suspend coverage and payment for drugs prescribed by providers who have  been engaged in misprescribing or overprescribing drugs with abuse potential;
  2. Suspend coverage and payment for Part D drugs when those prescriptions present an imminent risk to patients; and
  3. Require additional information on certain Part D prescriptions, such as diagnosis and incident codes, as a condition of coverage.
Look for these powers to be the subject of upcoming legislation. In addition, CMS stated that it is targeting individual prescribers to ensure only legitimate prescribers are appropriately prescribing to beneficiaries. CMS is going to implement its power, under Section 6405 of the Affordable Care Act, to require most prescribers of drugs paid for by Part D to enroll in Medicare. CMS is currently, actively working to enroll over 400,000 prescribers of Part D drugs by January 2016 and to enforce the requirement that plans deny Part D claims that are written by prescribers who do not meet the necessary requirements by June 2016. Finally, in addition to increasing its taskforce efforts and collaborating with plan sponsors and law enforcement, CMS also plans to increase its data analysis capabilities. CMS will be implementing quicker and more efficient data sharing and analysis with its Medicare Drug Integrity Contractor.  Those efforts should result in even higher numbers of inappropriate billings for opioid abuse being identified for investigation in the future.