While Congress mulls a proposed Medicare prescription drug benefit, the U.S. Justice Department is urging lawmakers to include "strong anti-fraud safeguards" in their plans.
Associate Deputy Attorney General John Bentivoglio, one of the department's top healthcare fraud fighters, said now is the time to craft such anti-fraud measures.
"In our view, taxpayers would be well-served by building strong anti-fraud provisions into the program at its inception, rather than waiting for fraud and abuse to occur," Bentivoglio told an audience at the Health Ethics Trust's annual best compliance practices forum in Washington last month. "This would provide a level playing field for providers, so that good corporate citizens would not be placed at a competitive disadvantage to less scrupulous providers."
Mark Pastin, president of the Alexandria, Va.-based Health Ethics Trust, said that creating a multibillion-dollar drug benefit could also create "a tremendous potential for fraud, abuse, patient rights violations and patient privacy violations.
"This threat will be particularly acute if private insurers administer the program, as many private insurers do not have protocols that satisfy the minimum compliance requirements of federal health programs," said Pastin, adding that his organization does favor a drug plan for needy seniors.
Some proponents of a Medicare prescription drug benefit echoed those sentiments.
John Rector, general counsel at the National Community Pharmacists Association, said his organization "would strongly favor" compliance measures that would create a paper trail to deter, or prove, inappropriate conduct.
"Almost all (Medicare drug) proposals involve some kind of private entities operating part of the program," Rector said. "Based on the notorious reputations of some of those (for-profit) entities, I could see why the government is thinking along those lines."
In particular, the Justice Department wants companies involved in the drug benefit to:
* Establish a comprehensive compliance program.
* Certify the accuracy of data submitted to the federal government, particularly data used to determine payment or reimbursement to the government.
* Report possible violations of law to the government.
The Medicare managed-care compliance guidelines released last year would serve as a good model for Medicare drug program compliance requirements, Pastin said.