Insurers participating in the Medicare Part D program varied widely in carrying out their responsibility to identify and respond to fraud and abuse, HHS inspector generals office concluded in an audit report.
Drug plan sponsors are required to have programs to detect incidents of fraud and abuse via internal reviews or notification from external sources such as law enforcement agencies, beneficiaries and the CMS. More than a quarter of 86 sponsors did not identify a single incident, and just seven of the sponsors accounted for about 90% of the 9,774 incidents, according to the review of data covering the first half of 2007. Of the ones that did find potential fraud and abuse, five did nothing about it, although the CMS asks that sponsors conduct inquiries, take corrective action and make referrals for further investigation.
The report recommends that the CMS investigate why some sponsors have logged particularly high or low numbers and to require all of them to routinely report the results of their fraud and abuse programs.
In a separate audit report, the inspector generals office found that the CMS has failed to live up to its plans to conduct routine audits of sponsors compliance plans. In response, acting CMS Administrator Kerry Weems wrote that the agency had to reprioritize its program oversight activities in response to funding shortfalls but that the audits would begin this fall. -- by Gregg Blesch