PCMA: 'Protect Your Pharmacy Week' Should Focus on Safeguarding Part D Anti-Fraud Tools

New Survey and Ad Highlight Fraud, Waste, and Abuse Problem

Merritt: 'Small Pharmacies Can Be Especially Vulnerable'

WASHINGTON, April 10 /PRNewswire-USNewswire/ -- A new survey of experts responsible for detecting and preventing pharmacy fraud, waste, and abuse in Part D finds that proposals requiring drugstores to be paid twice as fast as other Medicare providers would increase costs and make it more difficult to fight fraud, waste, and abuse, the Pharmaceutical Care Management Association (PCMA) said today. In addition to the new survey, PCMA is also launching a print advertising initiative that highlights how "finding the bad apples isn't easy" in detecting fraud, waste, and abuse and that proposals mandating "prompt pay" would make it even tougher.

"'Protect Your Pharmacy Week' is a good time to focus on safeguarding the tools needed to fight increasingly sophisticated and aggressive fraud tactics. Finding the 'bad apples' isn't always easy and small pharmacies can be especially vulnerable," said PCMA President and CEO Mark Merritt. "Part D plans employ a variety of state-of-the-art techniques when working with pharmacies and other stakeholders to combat fraud, waste, and abuse. Making plans pay drugstores twice as fast as other Medicare providers would increase costs and make fighting fraud, waste, and abuse more difficult."

Survey findings include:

-- Pharmacy Fraud, Waste, and Abuse Is Costly: Approximately 1 percent of prescription costs are likely due to fraud, waste, or abuse. This amounts to hundreds of millions of dollars in unnecessary costs for the Medicare Part D program and its beneficiaries.

-- Part D Plans Use Advanced Techniques to Combat Fraud, Waste, and Abuse: Part D plans use sophisticated software and auditing techniques to identify problematic prescription claims. Most plans screen for fraud, waste, and abuse both before and after a claim is paid. Problem claims can often be detected automatically, but auditors must then analyze the claims and often contact the pharmacy, doctor, or patient for additional information to determine if fraud, waste, or abuse has occurred.

-- Problem Claims Can Be Caught Prior to Payment: Typical examples of fraud, waste, and abuse detected prior to a claim being paid include prescription claims submitted with the improper quantity, improper days supply, improper coding, duplicative claims, and other irregularities.

-- "Prompt Payment" Mandates Would Increase Costs: Accelerated payment cycles would make it difficult or impossible to complete some fraud, waste, and abuse detection efforts that currently occur prior to payments being made. While the majority of payments made on claims involving fraud, waste, or abuse can eventually be recovered, this can be difficult, time intensive, and, in some cases, impossible. This results in increased costs.

-- Independent Pharmacies Tend to be More Vulnerable to Fraud than Large Chain Pharmacies: Unlike independent pharmacies, large chains have centralized billing operations with sophisticated accountability systems in place.

Merritt added: "Medicare's current 30-day payment cycle strikes the right balance between paying pharmacies promptly and protecting the integrity of the program."

-- New Survey: "Prompt Payment " Mandates Would Raise Costs Due to Pharmacy Fraud, Waste, and Abuse

-- New PCMA Print Ad: "Bad Apples"

-- Finding the "Bad Apples": Case Studies of Pharmacy Fraud Waste and Abuse

Available at: www.pcmanet.org

PCMA is the national association representing America's pharmacy benefit managers (PBMs), which administer prescription drug plans for more than 210 million Americans with health coverage provided through Fortune 500 employers, health insurance plans, labor unions, and Medicare Part D.

CONTACT: Charles Cote (202) 207-3605

SOURCE Pharmaceutical Care Management Association

Suggested Articles

The profit margins and management of Community Health Group raise questions about oversight of managed care insurers.

Financial experts are warning practices about the pitfalls of promoting medical credit cards to their patients.

A proposed rule issued by HHS on Tuesday would expand short-term coverage, a move Seema Verma said will have "virtually no impact" on ACA premiums.