The Office of Inspector General (OIG) says it all in the provocative, if not brief, title of its February 2020 report: The Majority of Providers Reviewed Used Medicare Part D Eligibility Verification Transactions for Potentially Inappropriate Purposes.
The OIG reviewed Part D eligibility transactions submitted by 30 different mail-order pharmacies and found that, out of 3.9 million transactions, 2.6 million had no association with a subsequent prescription.
So that’s not good.
The OIG selected the pharmacies based on large volumes of E1 transactions relative to the number of prescriptions ultimately processed. At the time of the audit, 10 of the selected entities were closed or already under investigation. The OIG determined another 15 were using, or hiring others to use, the system for inappropriate purposes.
Perhaps those findings are not surprising given that the sample selection criteria targeted entities with large numbers of requests and proportionately few processed Part D prescriptions. It seems like self-fulfilling prophecy. The more we consider the sampling techniques of these audits, the more skeptical we become of using the findings to support extrapolation and industry-wide application. Nonetheless …
As a result of the audit, expect CMS to:
SOURCE LINKS
https://oig.hhs.gov/oas/reports/region5/51700020.asp
The OIG reviewed Part D eligibility transactions submitted by 30 different mail-order pharmacies and found that, out of 3.9 million transactions, 2.6 million had no association with a subsequent prescription.
So that’s not good.
The OIG selected the pharmacies based on large volumes of E1 transactions relative to the number of prescriptions ultimately processed. At the time of the audit, 10 of the selected entities were closed or already under investigation. The OIG determined another 15 were using, or hiring others to use, the system for inappropriate purposes.
Perhaps those findings are not surprising given that the sample selection criteria targeted entities with large numbers of requests and proportionately few processed Part D prescriptions. It seems like self-fulfilling prophecy. The more we consider the sampling techniques of these audits, the more skeptical we become of using the findings to support extrapolation and industry-wide application. Nonetheless …
As a result of the audit, expect CMS to:
- Issue clear guidance to providers for the proper use of the system, specifically that it is not a database for marketing purposes and should only be used by entities that dispense prescription medications and submit those prescriptions for insurance reimbursement.
- Closely monitor suppliers with high numbers of eligibility inquiries.
SOURCE LINKS
https://oig.hhs.gov/oas/reports/region5/51700020.asp
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