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Part D Beneficiaries With Questionable Utilization Patterns for HIV Drugs

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Jodi Nudelman, Regional Inspector General for Evaluation and Inspections in New York, interviews Tom O'Donnell, a Special Agent in Charge for the Office of Investigations in New York, and Miriam Anderson, a team leader in the Office of Evaluation and Inspections.


Under Medicare Part D, CMS contracts with private insurance companies, known as sponsors, to provide prescription drug coverage. OIG has found that Part D is vulnerable to fraud, waste, and abuse. Prior work has focused on questionable practices by pharmacies and prescribers; this report addresses beneficiaries with questionable utilization patterns.

CMS has placed few restrictions on specific beneficiaries, and these restrictions have focused on opioids. For example, CMS's Overutilization Monitoring System provides each sponsor with a list of beneficiaries who are potentially overutilizing opioids. However, opioids are not the only Part D drugs vulnerable to fraud, waste, and abuse. Other types of drugs, including those that treat human immunodeficiency virus (HIV), are also vulnerable because they can be very expensive and can have psychoactive effects.


We based this study on an analysis of Prescription Drug Event records for HIV drugs in 2012. Part D sponsors submit one record to CMS for each drug that is dispensed to a beneficiary enrolled in their plans. Each record contains information about the drug, beneficiary, pharmacy, and prescriber. We developed six measures to identify beneficiaries with questionable utilization patterns on the basis of results of past OIG analyses and fraud investigations and on input from CMS staff.


Medicare Part D paid $2.8 billion for HIV drugs in 2012. Almost 1,600 Part D beneficiaries had questionable utilization patterns for HIV drugs. These beneficiaries had no indication of HIV in their Medicare histories, received an excessive dose or supply of HIV drugs, received HIV drugs from a high number of pharmacies or prescribers, or received contraindicated drugs (i.e., HIV drugs that should not be used in combination with one another). In total, Medicare paid $32 million for HIV drugs for these beneficiaries. While some of this utilization may be legitimate, all of these patterns warrant further scrutiny. These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market. They may also indicate that a pharmacy is billing for drugs that the beneficiary never received or that a beneficiary's identification number was stolen.


We recommend that CMS (1) expand sponsors' drug utilization review programs, (2) expand the Overutilization Monitoring System to include additional drugs susceptible to fraud, waste, and abuse, (3) expand sponsors' use of beneficiary-specific controls, (4) restrict certain beneficiaries to a limited number of pharmacies or prescribers, (5) limit the ability of certain beneficiaries to switch plans, (6) increase monitoring of beneficiaries' utilization patterns, and (7) follow up on questionable utilization patterns. CMS concurred with all but the second and fifth recommendations.