Drug Pricing and Reimbursement
This webpage pulls together the Office of Inspector General's (OIG) body of work since 2010 plus several older relevant items that relate to drug pricing and reimbursement in HHS programs. It features planned work, completed reports, industry guidance, and enforcement actions. It does not cover OIG's body of work focused on questionable or fraudulent billing for prescription drugs. The webpage on drug pricing and reimbursement will be updated periodically.
OIG makes recommendations to HHS that promote economy, efficiency, and effectiveness in the administration of HHS programs and operations. These recommendations generally stem from OIG's audits and evaluations. For a comprehensive list of unimplemented recommendations across HHS programs, see the Compendium of Unimplemented Recommendations.
Below is a list of the unimplemented recommendations in the drug pricing and reimbursement area that would most positively affect HHS programs in terms of saving money and/or improving quality and should therefore be prioritized for implementation. For a list of selected implemented recommendations and their associated impact, please see the Impact tab.
|Unimplemented Recommendation||Report||Work Area|
|CMS should require the use of claim-level methods to identify 340B drugs.||State Efforts to Exclude 340B Drugs from Medicaid Managed Care Rebates (OEI-05-14-00430) (Issue Date: 06-06-2016)||Program Compliance|
|HRSA should clarify its guidance on preventing duplicate discounts for MCO drugs.||State Efforts to Exclude 340B Drugs from Medicaid Managed Care Rebates (OEI-05-14-00430) (Issue Date: 06-06-2016)||Program Compliance|
|CMS should cooperate with industry stakeholder efforts to identify a solution to prevent coupons from being used to purchase drugs paid for by Part D.||Manufacturer Safeguards May Not Prevent Copayment Coupon Use for Part D Drugs (OEI-05-12-00540) (Issue Date: 09-18-2014)||Program Compliance|
|CMS should amend current regulations to decrease the Part B payment rates for dispensing and supplying fees to rates similar to those of other payers, such as Part D and Medicaid.||Medicare Part B Prescription Drug Dispensing and Supplying Fee Payment Rates Are Considerably Higher Than the Rates Paid by Other Government Programs (A-06-12-00038) (Issue Date: 09-15-2014)||Reimbursement Policy|
|CMS should work with States to improve the quality of claims data submitted by providers.||Medicaid Drug Rebate Dispute Resolution Could Be Improved (OEI-05-11-00580) (Issue Date: 08-19-2014)||Program Compliance|
|CMS should help States obtain better data on ineligible drugs drugs i.e., 340B-purchased drugs ineligible for Medicaid rebates.||Medicaid Drug Rebate Dispute Resolution Could Be Improved (OEI-05-11-00580) (Issue Date: 08-19-2014)||Program Compliance|
|CMS should examine the potential impacts of establishing a prescription drug rebate program under Medicare Part B and, if appropriate, seek legislative change.||Medicare Could Collect Billions If Manufacturers Were Required To Pay Rebates for Part B Drugs (OEI-12-12-00260) (Issue Date: 09-09-2013)||Reimbursement Policy|
|CMS should finalize the implementation of automated ASP-related procedures by using AMP-related processes as a model, and subsequently require all manufacturers to submit ASPs through the automated system that CMS is developing.||Limitations in Manufacturer Reporting of ASP Data for Part B Drugs (OEI-12-13-00040) (Issue Date: 07-21-2014)||Data Integrity|
|CMS should seek a legislative change to directly require all manufacturers of Part B drugs to submit ASPs.||Limitations in Manufacturer Reporting of ASP Data for Part B Drugs (OEI-12-13-00040) (Issue Date: 07-21-2014)||Data Integrity|
|CMS should consider seeking legislative authority to implement least costly alternative policies for Part B drugs under appropriate circumstances.||Least Costly Alternative Policies: Impact on Prostate Cancer Drugs Covered Under Part B (OEI-12-12-00210) (Issue Date: 11-21-2012)||Reimbursement Policy|
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Priority recommendations summarized.
OIG planned projects.
Significant OIG activities in 6-month increments.