OIG Report on “Questionable” Prescribing Practices Likely to Lead to Closer Scrutiny of Physicians

Today the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued a report revealing new data on prescribers with questionable billing patterns under the Medicare Part D program. The OIG conducted this study to investigate rising concerns of Medicare prescriber fraud.

According to the OIG’s report, over 700 of nearly 87,000 general-care providers had “questionable” Part D prescribing patterns. A total of 2,238 general-care providers were labeled as outliers, but 736 doctors had what the OIG considered to be “extreme” prescriber patterns. A majority of these “extreme” outlier physicians ordered what the OIG considered to be extraordinary quantities of Schedule II or III drugs. Other examples of “extreme” patterns included doctors writing over 400 prescriptions for one patient and the number of pharmacies dispensing a single doctor’s orders. The OIG’s report noted that “Although some of this prescribing may be appropriate, such questionable patterns warrant further scrutiny.”

The Centers for Medicare and Medicaid Services (CMS) contracts with sponsors that provide drug coverage to beneficiaries enrolled in Medicare Part D. In addition, CMS contracts with a Medicare Drug Integrity Contractor (MEDIC), a contractor responsible for detecting and preventing fraud and abuse. The OIG recommended that CMS heighten its oversight of the Medicare Part D program by working in conjunction with MEDIC and the private insurers. According to the report, CMS has agreed to the OIG’s following recommendations:

1. Direct MEDIC to expand its scrutiny of prescribers 2. Give private insurers that administer Part D more guidance on how to investigate prescribing patterns 3. Provide education and training for prescribers 4. Monitor prescribers with questionable prescribing patterns

Because CMS has agreed to work with MEDIC to expand its analysis of prescribers and follow up with individual physicians with questionable prescribing patterns, physicians can expect greater scrutiny of their prescribing habits in the upcoming months. This is especially concerning for physicians who treat patients for pain management. Physicians should be prepared to justify the medical necessity of narcotics and other prescriptions that could be called into scrutiny. If you need assistance defending a Medicare audit or need help creating a compliance plan to address pain management risk areas, please contact an experienced healthcare attorney at 248-544-0888.