• Skip to main content
  • Skip to secondary menu
  • Skip to primary sidebar
  • Skip to footer
California Health Advocates

California Health Advocates

  • Contact
  • Home
  • About Us
    • Contact
    • Our Team
    • Mission
    • Education Services
    • About HICAP
    • Press
    • Testimonials
  • MEDICARE COUNSELING
  • Fact Sheets
  • Topics
    • The Basics
    • Prescription Drugs
    • Low-Income Help
    • Medigap
    • Medicare Advantage
    • Other Health Insurance
    • Appeals
    • Billing & Claims
    • Disabilities
    • Long-Term Care
    • Tribal Nations & Medicare
    • Health Care Reform
    • Advocacy & Policy
    • Glossary
  • Fraud & Abuse
  • Blog
  • Donate

OIG Reports Show Part D is Vulnerable to Fraud & Provides Tips for Improvement

California Health Advocates > Fraud & Abuse > OIG Reports Show Part D is Vulnerable to Fraud & Provides Tips for Improvement

Posted by Karen Fletcher on July 7, 2015

Last month the Department of Health and Human Services (HHS) announced the largest ever national take down charging 243 individuals for $712 billion in fraudulent billing. Forty-four of those individuals were charged with fraud involving the Part D prescription drug benefit. The Office of Inspector General (OIG) recently released 2 reports on Part D fraud. As prescription drug fraud is on the rise, Part D fraud prevention and oversight is a new OIG priority.

The first report, Ensuring the Integrity of Medicare Part D, summarizes the OIG’s numerous investigations, audits, evaluations, and guidances related to Medicare Part D, and provides updates on the ways the Centers for Medicare and Medicaid Services (CMS) is addressing OIG-identified weaknesses in the Part D program. It notes that ~39 million beneficiaries receive Part D benefits through more than 2,000 plans sponsored by private companies (as of 2013), and that the Part D drug payments are approximately $121 billion per year. The OIG relies on 3 key players to monitor the integrity of the Part D program: Part D plan sponsors, CMS and the MEDIC (the Medicare Drug Integrity Contractor). Part D plan sponsors monitor and pay Part D claims; CMS oversees the program, and contracts with the MEDIC to perform program integrity functions; and the MEDIC investigates potential fraud and abuse referred to it through external sources, and identifies potential fraud and abuse through proactive methods, such as data analysis.

Screen-Shot-2015-07-06-at-2.25.43-PM1
From OIG report, Ensuring the Integrity of Medicare Part D, https://oig.hhs.gov/oei/reports/oei-03-15-00180.pdf.

 

 

 

 

 

 

 

 

 

 
Screen-Shot-2015-07-06-at-2.26.00-PM1

The OIG recommends that CMS, MEDIC, and Part D sponsors all increase their efforts to address Part D fraud and abuse. OIG also advises having increased data collection, including expanded reporting requirements and drug utilization review programs, and for the implementation of even more robust oversight efforts, including mechanisms to recover payments from Part D sponsors.

The second report, Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D looks at the sharp spending increase on frequently abused opioids in the last 10 years, highlights pharmacy-related fraud schemes related to opioids, and points out “geographic hotspots” for certain non-controlled drugs.

Screen-Shot-2015-07-06-at-2.41.30-PM
From OIG report: http://oig.hhs.gov/oei/reports/oei-02-15-00190.pdf

All Part D sponsors, pharmacies and providers should be aware of the OIG’s continuous efforts to identify and combat against potential areas of fraud in the Part D program.  Prescribers in any of the OIG’s current hotspots should also be prepared for increased scrutiny.

For more information, read the full reports:

  • Ensuring the Integrity of Medicare Part D
  • Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D

Filed Under: Fraud & Abuse

Previous Post: « CHA Supports Task Force to Create a Statewide Long-Term Care Program
Next Post: $4.8 Billion in Cuts to Social Security & SSI to Pay for Highways? Contact Congress to Say No! »

About Karen Fletcher

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

Related Posts

  • SMP Partner Spotlight ~ Meet Carla Diaz!
  • Genetic Testing Scams Are Rising – Protect Your Medicare
  • Fraud Prevention Week Teaches Everyone How to Prevent Fraud
  • SMP Ambassador Spotlight ~ Meet Wayne April!

Primary Sidebar

Change Text Size

  • 100%  110%  120%  130%  

News & Blog Categories

  • Medicare Advantage
  • Low-Income help
  • Medicare & Disabilities
  • Medicare Basics
  • Prescription Drugs
  • Medicare & Other Health Insurance
  • Medicare Billings, Claims & Appeals
  • Health Care Disparities
  • Fraud & Abuse

—

  • COVID-19
  • Resources
  • Health Care Reform
  • Long-Term Care
  • CHA News

—

  • Advocacy & Policy
  • Letters and Comments to Policymakers
  • Legislative and Congressional Testimony
  • Policy Briefs

Send Us Comment

Do you have comments or concerns about your Medicare coverage? Issues regarding getting your needed prescriptions from your Part D plan, or a Medicare Advantage plan representative's marketing practices? Let us know at comments@cahealthadvocates.org.

We are dedicated to making Medicare's program work well for all beneficiaries. Your feedback from your own or your client's concerns and experiences with Medicare, will guide our Medicare advocacy efforts with key policy and decision-makers in both California and nationally with the Centers for Medicare and Medicaid Services (CMS) and Congress.

Archives

Donate Today

Footer

Sign up for our newsletter

Choose the news you'd like to receive

Important Links

  • About Us
  • Fact Sheets
  • Blog
  • Donate
  • Contact
  • Privacy Notice
  • Cookie Policy
  • Accessibility Statement

Follow Us

Copyright © 2022 · California Health Advocates · Web Design by TWK Web and Print Design · Log in