“Part D auditing is really in its infancy, and what we are seeing today is not what we will be seeing in two years or five years from now,” says Jessica Gustafson, a partner with Health Law Partners, Southfield, Mich. “My takeaway would be that the Part D plans should be aware that there will be more auditing in the future.”
Some of the problems in auditing Part D are a result of the program's design. It's funded through a complex, population-based system known as capitation that pays health plans to provide for prescription drug coverage across large groups, which reduces the incentive to find individual incidents of fraud. Part D also has to compete for attention with the other fraud-prone sectors of Medicare that carry even larger price tags, such as the program's hospital and physician benefits.
But those complexities offer little comfort to people affected by diverted drugs prescribed by Medicare doctors whose aberrant practice patterns could have been caught by a quick-witted auditor or an algorithm.
“This problem is breaking down communities and killing people,” says Dennis Jay, executive director of the Washington-based advocacy group Coalition Against Insurance Fraud, which has studied the issue in the past.
Medicare Part D is “probably one area where there isn't enough focus being put on by government and the contractors, and that's because they're looking at other parts of Medicare right now,” Jay says. “We've been pushing them a little bit to focus more on drugs.”
No estimates exist for how severely prescription-abuse fraud affects Medicare Part D. A 2008 study from the insurance coalition said such fraud costs all insurers, public and private, about $72.5 billion—a price from a 2008 consultants' study that includes both direct costs of the drugs, the ancillary services and physicians' time used, and the cost of hospitalization and drug treatment for addicted individuals.
Meanwhile, the Centers for Disease Control and Prevention in Atlanta reported that the death rate for overdoses from prescription painkillers such as oxycodone, methadone, hydrocodone and oxymorphone tripled during the past decade, killing 15,500 people in 2009, the most recent year for which national data were available.
CMS officials and their auditing contractors declined interview requests for this story, but wrote in an e-mail, “CMS takes seriously fraud and abuse in Medicare Parts C and D, as well as oversight of those programs.”
But HHS' inspector general's office has issued numerous reports since 2006 noting a lack of oversight and aggressiveness in monitoring.
In January, an inspector general's report concluded that the Medicare drug integrity contractor, Health Integrity—whose job specifically includes a mandate to proactively find fraud in Part D—had done little of its own investigative work in looking for problems.
The inspector general's office cited numerous weaknesses in the system, including that health integrity lacked access to the data it needed. That has since been solved, CMS officials say, but the company still lacks the power to take enforcement actions like Medicare's zone program integrity contractors have over the program's hospitalization and physician benefits.
Instead, the company must rely on enforcement agencies such as the Justice Department or local prosecutors to take action. Yet of the 1,807 new investigations the company opened into Part D in 2011, only 184 were eventually referred to outside agencies. And of those referred cases, only 10% were developed by the company's own data analysis, according to the inspector general's January audit report. The rest of the cases came from tips from plan sponsors.
Officials with Health Integrity did not respond to requests for comment, though a CMS spokeswoman says the company's contract with the government forbids media interviews.
The Part D plan sponsors are a prime source of outside investigative leads for Health Integrity.
Pharmacy benefits manager Express Scripts is one such plan sponsor, holding Part D contracts to provide benefits directly to Medicare beneficiaries as well as pharmacy management services for other private insurers that outsource the service.
Express Scripts performs auditing work monitoring other government contractors that administer Plan D on behalf of Medicare.
Jo-Ellen Abou Nader, senior director of program integrity at Express Scripts, says her company uses sophisticated, proprietary algorithms to examine 290 different potential red flags for fraud and abuse in the 1.4 billion prescriptions the company manages per year, which include its Part D business.
“I'd say it's very active now,” Abou Nader says. “We've been in this space for several years.”
She says Express Scripts turns over to auditors every suspected case of fraud it finds among its direct Part D beneficiaries. Issues that Express Scripts finds in other insurers' populations are turned over to those companies. Abou Nader didn't know how many of those tips get forwarded for investigation.
Past reports from HHS' inspector general's office show that some Part D plan sponsors were far more active than others in reporting cases of suspected fraud. In 2008, 28% of the plan sponsors reported no fraud at all.
“Plan sponsors are the first line of defense against Part D fraud and abuse. However, we found that some plan sponsors did not identify any potential fraud and abuse incidents,” according to the 2008 inspector general's report. The office is already conducting a new review along the same lines as the 2008 study to track changes, with a due date in 2014.
Both the 2008 and 2013 reports from the inspector general's office noted that the CMS has not made it mandatory for the Part D sponsors to turn over investigative findings, which it recommended reversing. The CMS demurred on the topic in its official responses.
Abou Nader says one immediate change that could help the problem would be to give health plans the ability to “lock in” certain patients, as private insurers do. This would mean that Medicare patients whose records show unusual activity, such as visiting multiple doctors or pharmacies, could be locked into seeing a single provider or pharmacy for their pain drugs. She says the proposal comes up “in every meeting” regarding the issue of drug diversion in Part D.
“The CDC is calling this a national epidemic, which it is,” she says. “There are plenty of government officials behind this now, and they know that we need to make a change, and it is going to take everyone in the community to make a difference. It is not just law enforcement; it is everyone in the healthcare community.
“We have to get out in front of this,” Abou Nader says.
Follow Joe Carlson on Twitter: @MHJCarlson