Healthcare Business News

Suspect HIV drug prescriptions cost Medicare millions

By Bob Herman
Posted: August 6, 2014 - 3:15 pm ET

Medicare paid $32 million in 2012 for HIV drugs that were tied to questionable and potentially fraudulent uses, according to a new report from HHS' Office of Inspector General (PDF). In some instances, there was no indication the beneficiaries had HIV.

For example, the OIG found Medicare Part D covered more than $33,500 in HIV drugs for a 77-year-old Detroit woman two years ago, but her Medicare claims history showed no signs of HIV, nor was there evidence she visited the providers who prescribed her the medicines.

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In other examples, people went to great lengths to stockpile large quantities of the drugs.

A Florida man received almost $350,000 in HIV drugs. Thirty-two separate people prescribed drugs to the man, and he collected 284 total drugs from 20 different pharmacies. A 48-year-old beneficiary from Miami went to 28 pharmacies and had 16 different prescribers, with Medicare paying more than $198,000.

HIV drugs, covered by Medicare Part D, are susceptible to fraud and abuse, the OIG said, as are many prescription painkillers. The expensive HIV drugs are often peddled for a profit, or they are used in tandem with painkillers to enhance “intoxicating effects.”

The OIG said the questionable practices could still be legitimate, but they “warrant further scrutiny.”

“These patterns indicate that beneficiaries may be receiving inappropriate or unnecessary drugs,” the report said. “Other possibilities include that the pharmacy submitted claims for drugs never dispensed or that the beneficiary's identification was stolen.”

The OIG analyzed prescription records for all drugs that commonly treat HIV, and then based “questionable” uses on six measures: a person had no history of HIV; a person received more than two times the daily recommended dose of an HIV drug; a person received more than a 16-month supply of any HIV drug; a person received HIV drugs from six or more pharmacies; a person had six or more clinicians prescribing HIV drugs; and a person inappropriately combined HIV drugs.

Overall, Medicare Part D spent $2.8 billion on HIV drugs in 2012. Of that total, $32 million, or about 1.1%, went toward 1,600 Part D beneficiaries with suspicious patterns.

“In a program that is as big and important as Medicare, ongoing attention to potentially fraudulent claims is vital,” said Tricia Neuman, a senior VP at the Kaiser Family Foundation who has studied Medicare. “In the scheme of things, it's not a large share of Part D dollars, but it is important that the dollars are well-spent.”

The most common and expensive brand-name HIV drugs covered by Medicare are AbbVie's Norvir, Gilead Sciences' Truvada, Merck & Co.'s Isentress, Bristol-Myers Squibb Co.'s Reyataz, Janssen Pharmaceuticals' Prezista, and Atripla, a joint venture between Bristol-Myers and Gilead.

The OIG recommended the CMS work more with Part D's contracted health insurers and auditors to ensure HIV drugs are not being used improperly. The CMS mostly agreed with the suggestions, saying Congress also would have to approve certain measures to change the Part D program.

Follow Bob Herman on Twitter: @MHbherman

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