OIG to CMS: Ramp up Part D anti-fraud oversight

Fifty-four percent of Medicare Part D sponsors didn't report potential fraud and abuse data to the government between 2010 and 2012, and the Centers for Medicare & Medicaid Services (CMS) didn't use what little data it received then to monitor anti-fraud activities, an Office of Inspector General report concluded.

Released Tuesday, the OIG's report doesn't name nonreporting sponsors; however, Medco Containment Life Insurance Company and Humana--insurers that collectively cover 4 million people--apparently didn't report in 2012, ProPublica found.

Data showed sponsors' fraud and abuse identification varied widely, with zero to nearly 14,000 incidents reported annually. Twenty-eight percent of reporting sponsors opened no fraud and abuse inquiries in two years. And while CMS said it analyzed sponsors' reports, it didn't quality check the data or use them to monitor Part D, the OIG noted.

"Part D plan sponsors' efforts to identify and address potential fraud and abuse are crucial to protecting the integrity of the Part D Program," the report states, since program expenditures topped $67.1 billion in 2011.

CMS doesn't require Part D fraud and abuse reporting but instead encourages sponsors to volunteer this information.

Low reporting rates and data mismanagement concerns put CMS on the hot seat at a U.S. House Energy and Commerce Health Subcommittee hearing yesterday, according to Health Data Management.

OIG recommended four fixes, including that CMS should mandate Part D fraud and abuse reporting and tell sponsors how to count cases. CMS also should account for dramatic data deviations and share data with sponsors and law enforcement.

CMS disagreed with the first recommendation. "[R]equiring Part D sponsors to report all potential fraud and abuse would have the potential to inundate the agency and our contractors with an unwieldy amount of information that would not necessarily yield a better outcome in terms of stopping fraud," former CMS Administrator Marilyn Tavenner wrote in a statement included in the OIG report.

CMS has been faulted before for dropping the Part D program integrity ball: Previously, the agency failed to report provider disciplinary actions and didn't act against questionable prescribing practices.

For more:
- read the OIG report
- here's the ProPublica article
- see the Health Data Management article

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