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Recent Compliance Updates & Tips

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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) provided congressional testimony on the opioid crisis affecting federal health care programs. The OIG reported that prescription drug diversion is a serious component of the epidemic. Related fraud includes a range of criminal activity from prescription drug diversion to addiction treatment schemes. The OIG reported that 50,000 Americans died from drug overdoses in 2015, and over 60 percent were opioid-related. Additionally, the Centers for Disease Control and Prevention (CDC) reports that roughly three out of four new heroin users abused prescription opioids before using heroin.

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Past OIG reviews found that 14.4 million, or one-third of Medicare Part D beneficiaries, received an opioid prescription in 2016. Of that number, around 500,000 beneficiaries received “high amounts” of opioids and nearly 70,000 beneficiaries received “extreme amounts” of opioids. The OIG determined that beneficiaries receiving “extreme amounts” of opioids and beneficiaries who engage in “doctor shopping” are particularly vulnerable to opioid misuse or overdose. The OIG determined that 22,308 beneficiaries appeared to be doctor shopping, a practice which it delineated as involving individual beneficiaries with four or more prescribers and pharmacies, each.

Findings from the National Healthcare Fraud Takedown

Health care fraud enforcement saw its ceiling in 2017 with the OIG and Medicare Strike Force National Healthcare Fraud Takedown (“Takedown”). The Takedown led to 412 defendants within 41 federal districts. The defendants included over 100 doctors, nurses, and other licensed medical professionals prosecuted for their participation in health care fraud schemes totaling roughly $1.3 billion in false billings. Specifically, more than 120 defendants were charged for prescribing and distributing opioids and other narcotics. The Takedown also resulted in 295 new opioid-related exclusions from the Medicare and Medicaid programs.

The OIG identified 401 prescribers as having questionable prescribing patterns for those beneficiaries considered to be at “serious risk.” These prescribers wrote 265,260 opioid prescriptions for beneficiaries at serious risk, amounting to $66.5 million in billings to Medicare Part D. The patterns described above also raise the concern that those prescribers may operate “pill mills.” Pill mills are otherwise ordinary healthcare facilities that regularly and non-medically prescribe controlled substances.

The OIG recognizes that an integral part of protecting beneficiaries entails ensuring that prescribers act appropriately. Consequently, the OIG has a number of current, opioid-related audits and evaluations underway. Among several others, the OIG is: (1) addressing questionable prescribing patterns in Medicaid; (2) reviewing Medicaid program integrity controls; and (3) reviewing the CDC’s oversight of grants to support programs that monitor prescription drugs.

Four OIG Recommendations for CMS Related to the Opioid Crisis

  1. Medicare Part D has new “beneficiary lock-in authority,” which restricts certain beneficiaries to a limited number of pharmacies or prescribers. The OIG recommends that CMS should encourage implementation of this new authority to combat Part D fraud.
  1. Drug utilization programs can be helpful tools to identify other drugs susceptible to fraud, waste, and abuse. The OIG recommends that CMS expand these programs and monitor potential drugs and non-controlled substances that are used in combination with opioids.
  1. Plan sponsors are a necessary and preliminary line of defense against opioid fraud and abuse. However, there is little transparency in how sponsors identify and investigate matters. The OIG recommends that CMS collect comprehensive data from Part D plan sponsors to improve its oversight of their program integrity efforts.
  1. Inaccurate and incomplete data can stifle oversight of the Medicaid program. The OIG recommends that CMS improve its Medicaid data. To this end, CMS should establish a national data set to identify Medicaid trends and vulnerabilities.

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Strategic Management Services has decades of experience assessing hospital and health care compliance programs. If you have any questions about the effectiveness of your program, contact us online or give us a call at (703) 683-9600 to speak to an expert.

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