Not All Internal Controls Implemented by CDC Were Effective in Ensuring That World Trade Center Health Program Pharmacy and Medical Claims Were Paid According to Federal Requirements

The World Trade Center Health Program (WTCHP) is administered by CDC through its National Institute for Occupational Safety and Health (NIOSH). Under the WTCHP, pharmacy benefits and medical services are provided to eligible responders and survivors with certified health conditions related to the September 11, 2001, terrorist attacks.

Not all of CDC's internal controls were effective in ensuring that claims for WTCHP pharmacy benefits and medical services were paid in accordance with Federal requirements. We determined that the internal controls for reimbursing claims for pharmacy benefits and medical services were not always effective in ensuring that New York (NY) Metro area members' primary prescription drug insurance was billed by pharmacies to maintain the WTCHP as the secondary payer (2 claims), Nationwide Network prescribers of members' prescription drugs were WTCHP-authorized (2 claims), prescription refills were authorized (1 claim), and pharmacy benefit and medical service claims were reimbursed at or below appropriate payment rates (2 claims). The presence of an internal control deficiency does not necessarily mean that CDC improperly paid a WTCHP claim; however, ineffective controls may limit NIOSH's ability to prevent and detect inappropriate billings and payment for these services.

We recommended that CDC (1) establish a procedure for collecting and transmitting NY Metro area members' prescription drug insurance coverage information to Pharmacy Benefit Managers (PBMs) for benefits coordination, (2) establish a procedure to ensure that Nationwide Network members' prescriptions are written by authorized WTCHP prescribers, (3) require the PBMs to establish procedures to prevent the authorized number of refills from being exceeded, (4) establish a procedure for ensuring that pharmacy benefit claims are reimbursed at or below appropriate payment rates, and (5) determine whether medical service claims processed before October 22, 2012, were reimbursed at or below the appropriate payment rate and recoup any overpayments that occurred.

In written comments on our draft report, CDC stated that it generally concurred with our recommendations and described actions that it has taken or planned to take to address most of them.

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