Health and Human Services Office reveals potential fraud and abuse in Medicare Part D

A data brief recently released by the U.S. Department of Health & Human Services Office of Inspector General reveals a possible area of fraud in Medicare Part D.

“Since the Part D program went into effect in 2006, the Office of Inspector General (OIG) has had ongoing concerns about abuse and diversion of Part D drugs,” the brief said. “OIG reviews have revealed questionable billing associated with pharmacies, prescribers and beneficiaries involving both controlled and noncontrolled substances.”

Key points in the data brief include: spending for Part D drugs has more than doubled since 2006, especially in commonly used opioids; pharmacies with questionable billing raise concerns about fraud and abuse in Part D. More than 1,400 pharmacies had questionable billing in 2014; geographic hotspots, locations where average Medicare payments per beneficiary for drugs are greater than the average payments nationwide, for specific drugs point to possible fraud and abuse.

“CMS has made progress in its Part D program integrity efforts," the brief said. "However, the findings in this data brief and previous OIG work demonstrate that more needs to be done to address fraud and abuse. A program as expansive as Part D requires CMS to remain vigilant and to continually develop and refine methods to uncover, address and prevent fraud."