MEDIC Benefit Integrity Activities in Medicare Parts C and D

WHY WE DID THIS STUDY

This report focuses on the one Medicare Drug Integrity Contractor (MEDIC) responsible for detecting and preventing fraud, waste, and abuse in Medicare Parts C and D nationwide. The report provides an update on MEDIC identification of potential Part D fraud and abuse and is the first review of MEDIC antifraud (benefit integrity) activities for Part C.

HOW WE DID THIS STUDY

From CMS and the MEDIC, we collected data on the MEDIC's benefit integrity activities between April 2010 and March 2011.

WHAT WE FOUND

Although the MEDIC has benefit integrity responsibility for both Medicare Parts C and D, its Part C investigations and case referrals represented a small percentage of its benefit integrity activities. In addition, the lack of a centralized Part C data repository hinders the MEDIC's ability to identify and investigate Part C fraud. Moreover, the MEDIC reported that it is prohibited from sharing specific information with other program integrity contractors. Further, there is no mechanism to recover payments from Part C or Part D plan sponsors when law enforcement agencies do not accept cases involving inappropriate services for further action. Other barriers remain, such as prescription drug event data limitations; the lack of a requirement for sponsors to refer incidents of potential fraud and abuse; and the MEDIC's lack of authority to directly obtain information from pharmacies, physicians, and pharmacy benefit managers. Also, CMS does not require the MEDIC to submit data elements that could help CMS oversee the MEDIC's benefit integrity activities.

WHAT WE RECOMMEND

We recommend that CMS (1) provide the MEDIC with centralized Part C data; (2) clarify its policy and instruct the MEDIC as to under what circumstances the MEDIC may share specific information with other entities; (3) explore methods to develop and implement a mechanism to recover payments from Part C and Part D plan sponsors when law enforcement agencies do not accept cases involving inappropriate services for further action; (4) authorize the MEDIC to directly obtain information from entities such as pharmacies, physicians, and pharmacy benefit managers; (5) require Part C and Part D plan sponsors to refer potential fraud and abuse incidents to the MEDIC; and (6) enhance the MEDIC's monthly workload reporting requirements. CMS concurred with the first, second, and sixth recommendations; partially concurred with the third and fifth; and did not concur with the fourth recommendation.