1 Benefit Integrity Medicare Drug Integrity Contractor (BI MEDIC): Health Integrity, LLC Tasha Trusty, RN BI MEDIC, Nurse Investigator Manager

MEDIC Purpose and Goals 2 To assist the Centers for Medicare & Medicaid Services (CMS) in protecting the integrity of the Medicare Parts C and D programs by accomplishing the following objectives: Identify and prevent Medicare Parts C and D fraud, waste, and abuse, and refer instances to the appropriate law enforcement (LE) agency Support ongoing LE investigations by responding to requests for information Perform data analysis efficiently and proactively to evaluate inappropriate activity Assist with audits as needed Educate the public about MEDIC responsibilities and ways of protecting themselves and the Medicare program from fraud Monitor inappropriate agent/broker activities and interface with the Department of Insurance

3 Help Us Help You in the Fight STOP Non-Compliance And FWA STOP Non-Compliance And FWA

Who Commits Fraud, Waste, and Abuse? Plans Sponsors and Pharmacy Benefit Managers Pharmacies Prescribers/Physicians Opportunists and Beneficiaries 4

5 Plan Sponsors and Pharmacy Benefit Managers Inappropriate enrollment/disenrollment Inaccurate data submission Adverse selection –Retain health members –“Cherry picking” or the exclusion of certain groups from services TrOOP manipulation Prescription drug switching Inappropriate formulary decisions Fictitious employees or members Payments for deceased members

6 Plan Sponsors and Pharmacy Benefit Managers (continued) Under-utilization and denial of necessary covered medical care Bonus pools or withholding fees based on service utilization Misrepresentation of the plan –Physician to patient ratio –Physician qualifications –Access to care Fraudulent subcontracts Inappropriate financial incentives paid to facilities or beneficiaries to obtain enrollments

7 Pharmacies There are three kinds of pharmacies: retail, mail order, and long-term care –Prescription drug shorting –Dispensing expired or adulterated prescription drugs –Prescription forging or altering Signature logs Prior authorization forms Prescriptions –Inappropriate billing practices Billing for brand names when generics are dispensed Billing for covered drugs when non-covered drugs are dispensed Billing for non-existent prescriptions Charging retail vs. negotiated price

8 Prescribers/Physicians Bill for services that are not medically necessary Bill for services not rendered Provision of false information Theft of prescriber’s Drug Enforcement Agency (DEA) number or prescription pad Prescription drug switching Script mills

9 Opportunists and Beneficiaries Elderly beneficiaries –65+ Young beneficiaries –Under the age of 65 –Disabled/ESRD Relatives/friends of beneficiaries –Pick up prescription drugs at pharmacies –Steal prescription drugs from medicine cabinets Identity theft/fraud –Beneficiary representing themselves as physician/clinic staff –Beneficiary representing themselves as another beneficiary –Beneficiary allowing someone else to use their benefits

10 Opportunists and Beneficiaries (continued) Doctor shopping and pharmacy shopping –Multiple prescribers –Multiple pharmacies –Overlapping days supply Prescription forging or altering –E-prescription and tamper-proof pads are being utilized to deter this activity Resale of drugs on black market –Multiple scripts for narcotics or other drugs sold on the street/black market

11 Complaints Not Handled by the MEDIC Customer service issues with Plan Sponsors –Enrollment, disenrollment and premiums –TrOOP calculations –Formulary issues –Established appeals or grievances with Plan Sponsors –Beneficiaries seeking reimbursement from Plan Sponsors –Low Income eligibility/status Customer service issues may persist and accumulate to form compliance issues Fee For Service (FFS) or Original Medicare (Medicare Part A, Part B, DME, Home Health and Hospice) fraud, waste, and abuse –Some overlap can occur, especially if there is a concern that drugs are being inappropriately billed to Part B or Part D

12 Complaint Referrals to the MEDIC The content of the complaint should be: –Clear –Without acronyms –Non-judgmental –Factual –Have supporting documents such as the complaint, Plan Sponsor statements, notes, records, discussions with complainant, provider or beneficiary Utilize SMART FACTS to refer complaints whenever available to you

13 MEDIC Contact Information BI MEDIC: Health Integrity, LLC By phone: 877-7SAFERX ( ) By fax: In writing: Health Integrity Attention: MEDIC 9240 Centreville Road Easton, MD 21601

14 Questions and Answers