Part D MEDIC Update: Panel Discussion

Transcription

1 Part D MEDIC Update: Panel Discussion Stephanie Blaydes Kaisler CMS Program Integrity Group Health Care Compliance Association December 11, 2007

2 Update on Part D Issues Overview I. MEDICs II. Coordination with Law Enforcement, State Insurance Commissioners and Special Investigation Units III. Regulation Changes 2

3 MEDIC Regional Map The 3 MEDIC Regions: Effective 12/1/06 WA MT OR ID WY NV UT CO CA #1: SAIC (West) AZ NM ND MN WI SD #2: EDS (North) NE IA IL KS MO OK AR VT NY MI PA NJ IN OH WV VA KY TN NC SC ME NH MA CT RI DE MD AK TX LA MS AL GA #3: Delmarva/ Health Integrity (Southeast) FL PR Mariana Islands HI Guam American Samoa USVI 3

4 MEDIC Contact Information RO #1 West: Science Applications International Corporation (SAIC) By phone: 877-7SAFERX ( ) By fax: *In writing: SAIC- MEDIC West 450 N. Brand Boulevard, Suite 410 Glendale, CA RO #2 North: Electronic Data Systems (EDS) Corporation By phone: 877-7SAFERX ( ) By fax: *In writing: EDS MEDIC-North 225 Grandview Avenue Mail-stop F10 Camp Hill, PA RO#3 Southeast: Delmarva/Health Integrity By phone: 877-7SAFERX ( ) By fax: *In writing: Health Integrity Attention: MEDIC 9240 Centreville Road Easton, MD *Note: All Regional MEDICs can be reached by the same number:

5 Fundamental MEDIC Activities Conduct complaint investigations Perform data analysis efficiently and proactively to evaluate inappropriate activity Develop and refer cases to the appropriate law enforcement (LE) agency or take administrative action as appropriate Support ongoing LE investigations Conduct audits as necessary Review PDP and MA-PD fraud and abuse compliance programs based on Chapter 9 of the Part D Manual Part D Program to Control Fraud, Waste, and Abuse 5

6 Part D MEDIC Update: Panel Discussion Judith M. Olshin Program Director, West MEDIC Science Applications International Corporation Health Care Compliance Association December 11, 2007

7 Agent / Broker Practices Objectives Brief overview of Medicare Part D Enrollment Prohibited Agent Marketing Practices Agent/Broker Fraud and Abuse Schemes & Practices Fraud detection measures Fraud case development Fraud deterrence 7

8 Beneficiary Enrollment The Medicare Part D drug benefit is offered to Medicare beneficiaries through: Medicare Advantage Prescription Drug plans (MA-PDs), Private Prescription Drug plans (PDPs), Managed Care plans PACE Plans Individuals may enroll in and disenroll from a Prescription Drug Plan (PDP) plan, or choose another PDP plan during the: Initial Enrollment Period for Part D (IEP for Part D) Annual Coordinated Election Period (AEP) Special Enrollment Periods (SEP) Part D Sponsors market their plans to beneficiaries to increase and sustain plan enrollment 8

9 Beneficiary Enrollment Organizations and its agents/brokers may not: Distribute any marketing materials until they receive approval and notification from CMS. Distribute marketing materials that are materially inaccurate, misleading, or otherwise make material misrepresentations. Misrepresent themselves or the benefits and services they provide. Claim within its marketing materials that it is recommended or endorsed by CMS, Medicare, or the Department of Health & Human Services. However, it may explain it is Medicare approved. Conduct door-to-door marketing Send unsolicited s to beneficiaries Make outbound calls to enroll beneficiaries 9

10 Agent / Broker Issues The Unscrupulous agent profile: Targets vulnerable Medi-Medi population Equipped with lists Motive $$$$$ Coming to home or health care facilities uninvited Cold calling from an appropriated list to enroll beneficiaries Deceptive Marketing/Agent Issues Bait and switch Free plan Medicare employee Plan endorsed by Medicare Coverage loss False statements regarding plan benefits Threats 10

11 Agent / Broker Issues Enrollment without consent Beneficiary didn t realize they were being enrolled when they talked to agent Agent contact confirmation Attendance sheets Forgery Enrolling unqualified beneficiaries into specific plans Enrolling dead beneficiaries Reverse Enrollments (Welcome Package) 11

12 Fraud Detection: Agent / Brokers Sources Call Center SHIPs/HICAPs Senior Medicare Patrol Department of Insurance/State Insurance Commissioners Part D Sponsors Data Analysis/Complaint Trending and Tracking Internal Tracking Systems Complaint Tracking Module (CTM) CMS Enrollment Data Systems Beneficiary Enrollment Changes Enrollment History 12

13 Agent/Broker: Fraud Case Development Conduct investigations of potential fraud and abuse Develop and refer cases to the appropriate law enforcement agency Recommend administrative actions as appropriate Education Suspension Exclusion Case example 13

14 Fraud Deterrence Coordination, Education, and Outreach activities SHIPs/HICAPs Senior Medicare Patrol Department of Insurance/State Insurance Commissioners Part D Sponsors Other Medicare Contractors 14

15 Part D MEDIC Update: Panel Discussion Sandy Love Program Director, South East MEDIC Health Integrity Health Care Compliance Association December 11, 2007

16 Part D Pharmacy Investigations False Billing Cases Sneaky Billing Cases Forgery Cases Substitution Cases 16

17 False Billing Cases Stolen Medicare Part D IDs Systematic pattern of drugs High Cost HIV, Cancer, Psych Dramatic rise in monthly billing Closed EOB errors 17

18 False Billing Cases HIV Drugs Combivir Epivir Kaletra Valcyte Viracept Truvada Serostim (Human Growth hormone) Psych Abilify Zyprexa Geodon Risperdal Seroquel Cancer Geevec 18

19 Sneaky Billing Cases Monthly billing increase Legitimate patients Add in high end drug $500 to $1000 Systematic EOB errors 19

20 Forgery Cases Signature Logs Prior Authorization Forms Prescriptions 20

21 Substitution Cases Generic for brand PAP drugs 21

22 Investigating Pharmacy Cases Partnerships OIG FBI DEA DOH BOP Tools Part D Data Audits Complaints Fraud Alerts MFCU PSCs Part D Sponsors (Plans) 22

23 Part D MEDIC Update: Panel Discussion Douglas Quave Program Director North MEDIC Safeguard Services, LLC Health Care Compliance Association December 11, 2007

24 Who are DSBs? Elderly Beneficiaries 65+ Young Beneficiaries Under the age of 65 Disabled/ESRD Dual eligible beneficiaries Medicare/Medicaid Relatives/Friends of Beneficiaries Pick up meds at pharmacies Steal meds from medicine cabinets 24

25 Why do They do It? Addiction $$$ Sell prescriptions Sell medications Or Both 25

26 Identifying DSBs Data Analysis Multiple scripts for narcotics or other drugs sold on the street/black market Multiple prescribers Multiple pharmacies Overlapping days supply Complaints Receive complaints from toll free number Complaints from SIUs, OIG Hotline, etc. Internet Identify beneficiaries/providers arrested by local law enforcement for drug activity Reports from Law Enforcement Receive information regarding arrests/persons of interest 26

27 Substantiating the Allegation Review Data Analysis Identify trends of beneficiaries receiving multiple scripts from multiple prescribers for meds that have potential for abuse Interviews with Complainants, Pharmacists, Physicians, etc. Determine whether this person is a known user Does the prescriber have record of the patient? Obtain Medical Records Do the medical records from the PCP list the medications? Is it noted in the records that the meds were prescribed to the patient? 27

28 Now What? Refer to OIG Refer to FBI Refer to Local Law Enforcement 28