CMS Tightens Controls on Medicare Prescribing

Marcia Frellick

May 21, 2014

Changes designed to curb fraud and abuse in prescribing drugs through Medicare Advantage and Part D programs are expected to save $1.6 billion over the next 10 years, the Centers for Medicare & Medicaid Services (CMS) says.

CMS on May 19 issued final regulations that include tighter restrictions on prescribers. Among them is a requirement that physicians and other providers be enrolled in Medicare, or have a valid opt-out affidavit on file, for the drugs to be covered under Part D. Although most physicians are already enrolled, CMS says, anyone not enrolled would have until June 1, 2015, to do so.

The final ruling extended the original time frame from January 1 after a public comment period, which drew over 7500 responses, registered criticism about the transition time.

The ruling follows reports detailing abuses. One released in June 2013 by the Office of Inspector General (OIG) of the US Department of Health & Human Services found that in 2009, Medicare Part D inappropriately paid for 72,552 prescriptions totaling $5.4 million ordered by 14 prescriber types who don't have the authority to prescribe in any state, such as massage therapists, athletic trainers, and dental hygienists.

Tens of thousands of these drugs were controlled substances, the report notes, which is of particular concern because of the potential for abuse.

CMS also states in the final regulations that it can revoke a physician or eligible professional's enrollment in Medicare if it finds a pattern of prescribing that is abusive, puts patients at risk, or otherwise fails to meet requirements. CMS can also revoke a prescriber's enrollment if his or her Drug Enforcement Administration Certificate of Registration is suspended or revoked.

The final rule cites another OIG report, which included examples of questionable prescribing practices. In one example, Medicare in 2009 paid a total of $9.7 million — 151 times more than the average — for one California doctor's prescriptions. Most of the prescriptions were filled by 2 pharmacies, both of which were on the OIG's radar as having questionable billing practices.

In another, a Texas physician ordered more than 400 prescriptions each for 16 Medicare patients and prescribed 700 or more drugs for 3 of these beneficiaries, the report said.

Closing loopholes and strengthening requirements will ultimately improve healthcare and help contain costs, Marilyn Tavenner, CMS administrator, said in a statement. "The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D program so that we can continue to protect beneficiaries and taxpayers," she said.

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