Medicare Part D paid $32 million in 2012 for drugs to treat HIV for people who may not have needed or received these medications, according to a study by the Office of Inspector General.
The OIG found questionable billing for 1,578 beneficiaries, 38 percent of whom lived in Miami or New York. Eyebrow-raising patterns included claims for high doses of HIV medications, claims for visits to multiple pharmacies, claims for incompatible drugs or claims for HIV drugs for people with no apparent HIV diagnosis.
"While some of this utilization may be legitimate," the report stated, "all of these patterns warrant further scrutiny." HIV drugs are prone to fraud, waste and abuse since they're costly and sometimes desired for their psychoactive effects, the OIG noted.
Some examples highlighted in the report:
- A 77-year-old woman reportedly filled prescriptions worth $33,500 for 10 different HIV drugs even though there were no signs that she received HIV-related medical care.
- A beneficiary in Miami received HIV drugs worth almost $200,000 from 28 pharmacies, with prescriptions reportedly written by 16 providers.
- Another patient received $17,500 worth of HIV drugs on one day with no subsequent HIV drug prescriptions in 2012.
"These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market," the report states. "They may also indicate that a pharmacy is billing for drugs that a beneficiary never received or that a beneficiary's identification number was stolen."
Managing HIV drug utilization is challenging in Medicare since these drugs are in a "protected class," noted an article co-published by ProPublica and The Washington Post. This means Part D sponsors must cover HIV drugs and can't require precertification for them as a condition of benefit payment.
The OIG recommended that the Centers for Medicare & Medicaid Services take remedial actions including expanding drug review programs and beneficiary-specific utilization controls.