HEALTH

Efforts to combat Medicare fraud draw mixed signals from indies, PBMs

BY Jim Frederick

WASHINGTON The independent pharmacy and pharmacy benefit management industries both praised new efforts by Congress and the Obama administration to end the fraudulent and abusive billing practices that plague Medicare and Medicaid and cost U.S. taxpayers tens of billions of dollars. But their recommendations for combating the problem are as different as their approaches to the pharmaceutical market.

The Centers for Medicare & Medicaid Services proposed new regulations to help prevent what the agency said is $55 billion in annual improper payments to providers and health plans. In a related development, the House Energy and Commerce Subcommittee on Health is looking at ways to attack the problem, and held a hearing Thursday titled, “Cutting Fraud, Waste and Abuse in Medicare and Medicaid.”

The National Community Pharmacists Association weighed in with a statement to the House panel that accused the pharmacy benefit management industry of responsibility for much of the abuse, which the group attributed to a “past record of alleged systematic chicanery.”

In its statement, the independent pharmacy lobby reminded lawmakers of numerous allegations of fraud by major PBMs, as well as “misrepresentation to plans, patients and providers; improper therapeutic solutions; unjust enrichment through secret kickback schemes; and failure to meet ethical and safety standards.” The group urged Congress to pass legislation “to rein in the waste being generated by the business practices of pharmacy benefit managers under Medicare and Medicaid,” and to increase the transparency of PBM audit practices.

Not surprisingly, the response from the Pharmaceutical Care Management Association, the main PBM industry advocacy group, was markedly different. Responding to new proposed regulations from CMS to combat fraud and abuse, PCMA president and CEO Mark Merritt said the government’s focus should be on preventing abuse rather than on pursuing wrongdoers after the fact for fraudulent billing practices. “Pharmacy benefit managers agree that prevention, not ‘pay and chase,’ is the key to fighting fraud,” Merritt noted. “Unfortunately, some public policies undermine the fight against fraud by requiring payers to include pharmacies in their networks that have been banned from federal programs.”

Merritt also reiterated PCMA’s call for legislation to eliminate legislative “prompt-pay” requirements that force pharmacy benefit plans to quickly pay prescription claims, raising again a major source of friction between the PBM and retail pharmacy industries. Policies that require payers to “accelerate payments,” PCMA’s leader charged, leave “less time to detect and prevent fraudulent Medicare claims before payments are made.”

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ScriptPro becomes pharmacy automation systems provider for NIH

BY Alaric DeArment

MISSION, Kan. The National Institutes of Health has retained ScriptPro as a provider of pharmacy automation systems, ScriptPro said.

 

The NIH, based in Bethesda, Md., will use ScriptPro’s robotic dispensing, pharmacy management and drug information systems to assist in the internal control and identification of drugs and to enhance the safety and efficiency of medication dispensing and use by patients.

 

 

ScriptPro already provides pharmacy automation systems to the Veterans Health Administration, the Food and Drug Administration, the Department of Defense, federal prisons and public health services, the company said.

 

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SIGIS updates Eligible Products List

BY Michael Johnsen

SAN RAMON, Calif. The Special Interest Group for IIAS Standards announced Wednesday that the group is making significant changes to its Eligible Products List — a list of over-the-counter products eligible for reimbursement under flexible spending accounts — in response to IRS guidance issued earlier this month.

That guidance, issued by the IRS in Notice 2010-59 in response to changes made by the Affordable Care Act, requires a doctor’s prescription for the reimbursement of over-the-counter drug and medicines from health plans and tax-advantaged healthcare accounts.

Based on this IRS guidance, the SIGIS Eligible Products List committee completed a thorough review of the list and determined that just more than 15,000 items are impacted and will need to be removed. Even after this significant reduction, more than 27,000 OTC items remain on the list for purchase without a prescription and through a Health Care Debit Card at SIGIS-certified merchants without the need for further substantiation. Items that continue to be eligible without a prescription include such items as insulin, medical devices (crutches, blood sugar monitors, etc.), bandages, contact lens solution and denture bond.

 

Though the IRS rule goes into effect on Jan. 1, 2011, SIGIS is releasing a summary of the edits to help SIGIS members begin to prepare for this significant change, the group noted. The detailed SIGIS Eligible Products List will be published on Dec. 15. In the guidance, the IRS granted transitional relief for IIAS merchants, so that IIAS merchants will actually have until Jan. 15, 2011, to update their systems to be compliant with the new guidance.

 

 

The following categories have been removed from the Eligible Products List to prevent them from being purchased at an IIAS merchant without a prescription. Categories no longer eligible without a prescription include:

  • Acid controllers;
  • Allergy and sinus medicine;
  • Antibiotics;
  • Antifiarrheals;
  • Antigas products;
  • Anti-itch and insect bite products;
  • Antiparasitic treatments;
  • Baby rash ointments/creams;
  • Cold sore remedies;
  • Cough-cold and flu products;
  • Digestive aids;
  • Feminine antifungal/anti-itch products;
  • Hemorrhoidal preps;
  • Laxatives;
  • Motion sickness products;
  • Pain relievers;
  • Respiratory treatments;
  • Sleep aids and sedatives; and
  • Stomach remedies.

 

 

SIGIS was formed to create a standard industry solution that could be both scaleable and broadly adoptable, while being consistent with IRS requirements. The group includes all stakeholders involved with the process, from pharmacy merchants through plan administrators.

 

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