Medicare drug plans to withhold pay if they suspect "doctor shopping"

Federal officials write a memo instructing Part D payers to end the "pay-and-chase" model for fighting improper drug claims.

By Charles Fiegl — Posted Dec. 22, 2011

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The Obama administration announced new payment policy measures to prevent patients from abusing painkillers and diverting drugs.

The Dept. of Health and Human Services has asked Medicare Part D sponsors to take extra precautions to stop improper payments for prescription drugs. The administration wants drug plans to raise red flags when they see suspicious claims or notice patterns that may indicate "doctor shopping" for prescriptions, said HHS Secretary Kathleen Sebelius. Part D plans processing prescriptions can be valuable partners in fraud prevention, she said.

"If they see fraud, they should withhold payment until they are able to verify the claim is legitimate," Sebelius said. "We also are making it easier for plans to report fraud to HHS and law enforcement officials."

The department was reacting to an October Government Accountability Office report estimating that 170,000 Medicare patients received prescriptions from five or more doctors for frequently abused drugs, such as OxyContin and Percocet. For instance, one Georgia patient received oxycodone prescriptions from 58 doctors, which amounted to a 1,679-day supply of pills. The activity was noticed when one physician suspected that the patient was selling the narcotics and refused to give her refills.

On Dec. 13, Medicare officials sent a memo stating that prompt-pay requirements inadvertently have created a "pay-and-chase" environment. The agency sought to clarify its policy by instructing drug plans to investigate and hold claims suspected of fraud. Payment should not be made until the claims have been determined not to be fraudulent.

Part D sponsors are encouraged to "implement reasonable prior authorization requirements" for opioids and other drugs susceptible to abuse and diversion. Plans also are directed to promote to doctors a policy of prescribing supplies of these drugs that cover fewer than 30 days.

In response to the GAO report, the American Medical Association said the best way to prevent doctor shopping is through state prescription drug monitoring programs. The AMA had warned that placing limits on how patients obtain prescriptions could have unintended consequences on patient care.

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