The Centers for Medicare & Medicaid Services has instructed all Medicare Part D and Medicare Advantage plan providers to withhold payments for popular painkillers if they suspect patient abuse.
The directive, issued December 13, is designed to curb both prescription drug abuse and Medicare fraud.
The government wants providers to be more aware, looking for suspicious activity related to the prescribing of OxyContin, Percocet, and other narcotics and painkillers. According to The Government Accountability Office, “170,000 Medicare beneficiaries received prescriptions from five or more” doctors for drugs such as OxyContin and Percocet.
“Abuse of painkillers is also responsible for more deaths than illegal drugs like cocaine and heroin combined,” noted redOrbit, quoting data from the The Centers for Disease Control and Prevention (CDC) in its summary of the directive. The agency said that as of 2010, 12 million Americans were using prescription opioid or narcotic pain relievers.
Medicare fraud related to prescription drugs takes a couple of common forms. Some patients will visit numerous doctors to get multiple prescriptions for OxyContin, Percocet, and other painkillers and narcotics to sate their addiction. Some patients sell the extra drugs obtained fraudulently.
The U.S. Department of Health and Human Services (HHS) stated that “OxyContin and Percocet abuse, prescription drug fraud, and so-called ‘doctor shopping’ are major problems. As an example, the agency says it found one Medicare recipient received prescriptions for a total of 3,655 oxycodone pills [such as OxyContin]… from 58 different prescribers.”
The agency’s guidance specifically tells prescription drug plan providers to withhold payment on suspicious claims to pharmacies until it verifies the claim as valid and to use mechanisms such as prior authorization.
HHS is also asking doctors to issue prescriptions for painkillers that provide a supply of 30 days or less. With prior authorization, a physician would have to submit a form and get approval from the plan before issuing a Medicare beneficiary’s prescription.
Part D plans also can conduct retrospective reviews of all a Medicare recipient’s prescription drugs, and “if a pattern of overutilization of opioids is determined through beneficiary-level retrospective review, sponsors can require documentation to determine medical necessity and may deny payment for subsequent claims if insufficient evidence is obtained to substantiate Part D coverage eligibility,” the memorandum said.
Kathleen Sebelius, U.S. Health and Human Services Secretary, said:
Prescription drug misuse has a serious human and financial cost. [...] The Obama Administration is making unprecedented strides in cracking down on fraud that contributes to this problem while costing taxpayers dollars. With these actions, we are going to continue to stop fraud before it happens and make sure that those who do defraud taxpayers are held accountable.
The announcement was part of an address by U.S. Vice President Joseph Biden in which he detailed “Campaign to Cut Waste” programs, including ending the continued production of presidential dollar coins. He stated that $5.6 billion from fraud was recovered in 2011. Of that, $2.9 billion was related to health care fraud, and Biden says some of that was the result of fraudulent claims being identified prior to a bill being paid.
BNA’s James Swann writes that the Medicare Fraud Strike Force, which consists of the Department of Justice and HHS personnel in nine U.S. cities, “brought cases involving more than $1 billion in fraudulent claims” last year. The new directive, says Sebelius, is designed to support “continuing efforts to move away from the existing pay-and-chase enforcement model to a model that would prevent improper payments in the first place.”