With Medicare Part D, all Medicare beneficiaries have access to the Medicare drug benefit through private plans approved by CMS. The drug benefit is offered through stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans. Part D is a market model, transferring risk to private plan sponsors, which then act as the insurers for Part D benefits.
Through Medicare Drug Integrity Contractors, or “MEDICs,” CMS developed a strategy to investigate and recommend prosecution for Part D fraud and abuse. MEDICs’ responsibilities include, but are not limited to: fulfilling requests for information from law enforcement agencies; investigating potential Part D fraud and abuse; referring cases and making immediate advisements regarding potential Part C and Part D fraud and abuse to the Office of Inspector General (OIG); recommending appropriate administrative actions to CMS; identifying program vulnerabilities; and auditing the fraud waste and abuse programs that are part of plan sponsors’ compliance plans.
Potential Part D False Claims Act violations for whistleblower claims include: submitting claims or other false documentation for drugs not provided; submitting claims or other false documentation for brand name drugs when generics are dispensed; submitting claims or other false documentation for non-covered drugs as covered; submitting claims or other false documentation to multiple payors for the same prescription (except as required for coordination of benefit transactions); failure to apply “maximum allowable cost” pricing to drugs, submitting claims or other false documentation concerning drugs containing other false representations to CMS, including but not limited to: false physician identifiers, and brand-name drugs when generics were dispensed.
Manufacturer Part D fraud can also take the form of unlawful kickbacks, to either the dispensing provider or the Part D Plan, or the submission of false information in connection with its obligation under the Discount Program Agreement.