NCPA Urges Measured Approach on Medicare Part D Fraud Prevention

Congress, Medicare and industry stakeholders should strike the right balance to cut out fraud in the Medicare Part D drug program while preserving patient access to critical medications.

PRESS RELEASE ALEXANDRIA, Va. (July 14, 2015) —

Congress, Medicare and industry stakeholders should strike the right balance to cut out fraud in the Medicare Part D drug program while preserving patient access to critical medications, the National Community Pharmacists Association

(NCPA) said in comments submitted in conjunction with a House Energy and Commerce subcommittee hearing today on the topic.

“Independent community pharmacists are proud to play a vital role in the Medicare Part D program, and have been on the front lines of providing medications, related counseling, and assistance with plans since the inception of the Part D program,” said NCPA

CEO B. Douglas Hoey, RPh, MBA

. “More than any other segment of the pharmacy industry, independent pharmacies are often located in the underserved and rural areas that are home to many Medicare recipients. While NCPA remains supportive of efforts to prevent and reduce fraud, waste and abuse within the Medicare Part D program, they must be delicately balanced with ensuring appropriate patient access to vitally important medications.”

NCPA’s comments included the following recommendations:

  • The Centers for Medicare & Medicaid Services (CMS) should require Part D plan sponsorsto report potential fraud and abuse or preventative steps taken by the plan sponsor. The Department of Health and Human Services Office of Inspector General (OIG) recently recommended such a mandate because the agency determined that under the current voluntary reporting system fewer than 50 percent of plan sponsors report such info.
  • Continue with current drug utilization review programs, such as for controlled substances, but refrain from expanding such reviews to additional drug therapies because it could be unduly burdensome and impact timely care for patients.
  • Any examination of “questionable pharmacy billing practices” must take into account legitimate patient care circumstances. For example, a community pharmacy that serves a large number of oncology or pain management practices may dispense more controlled substances than other pharmacies.
  • Any “lock-in” proposal to restrict certain beneficiaries to a specific pharmacy or prescriber must include beneficiary protections. In virtually all of the 46 state Medicaid “lock-in” programs, the beneficiary retains the ability to choose both the in-network prescriber and pharmacy. Without such protections the plan sponsor could simply assign beneficiaries to a pharmacy in which it has a financial interest.