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Drugstore Lobby Looks for 'Free Pass' to Avoid Fraud, Waste, and Abuse Detection
Date:8/3/2011

hes between inventories and prescriptions and other discrepancies." NHCAA also warns that "proposed federal and state legislation that would require payers to provide providers advance warning of an audit – even in cases when fraud is suspected – would give suspects time to tamper with evidence and evade authorities altogether." Unfortunately, legislation championed by the independent drugstore lobby would grant pharmacies (even those with wasteful or abusive practices) an advance notice "heads up" before being audited.
  • Policies that undermine authority across Medicare to suspend payments when there is suspicion of fraud. The ability to stop fraud before paying a claim is more effective and more efficient than relying on paying first and then chasing after claims that are later found to be fraudulent. Congress should extend to Medicare Part D the recently enacted statutory authority Congress provided in Medicare Parts A and B to suspend payment to health care providers upon a credible allegation of fraud, waste, or abuse.
  • Policies that reduce payers' time to verify pharmacy claims before payment ("Prompt Pay" policies). NHCAA states: "if claims are not rushed through the payment process, auditors and investigators will have more opportunities to detect attempts at fraud before they come to fruition." So-called "prompt pay" laws in Medicare Part D that mandate rapid payment to independent pharmacies reduce the time available to detect pharmacy fraud, waste, and abuse.
  • Policies that make payers partner with pharmacies that are banned from federal programs ("Any Willing Pharmacy" policies). Legislation that would force plans to include in their networks pharmacies that have been banned from federal programs "runs counter" to preventing fraud, according to NHCAA. This "low standard of admission could allow for the participation in employer networks of pharmacists who have been suspended from
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  • SOURCE Pharmaceutical Care Management Association
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