New analysis examines guiding principles for policymakers to fight health care fraud

In light of the recent historic Medicare fraud bust, a new analysis that examines the "Seven Guiding Principles for Policymakers" to fighting health care fraud invites new questions about legislative efforts to reduce accountability and oversight of independent pharmacies, the Pharmaceutical Care Management Association (PCMA) said today.

"Some policies meant to help independent pharmacies inadvertently open the door to fraud, abuse, and wasteful spending. It's bad policy to make private payers partner with independent drugstores that are suspected of fraud, can't be effectively audited or have been banned from federal programs," said PCMA President and CEO Mark Merritt.

The white paper was released by the National Health Care Anti-Fraud Association (NHCAA), the leading national organization focused exclusively on combating health care fraud. The "Seven Guiding Principles for Policymakers" seek to address the estimated $70 to $234 billion in annual financial losses resulting from fraud throughout the health care system and warns policymakers to avoid policies that could undermine fraud fighting efforts.

Specific questions should be raised about the following legislative proposals promoted by the independent pharmacy lobby:

• Policies that make payers partner with pharmacies that are banned from federal programs ("Any Willing Pharmacy" policies).
  • Legislation (HR 4199, the "Patient Health and Real Medication Access Cost Savings Act of 2009") 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 bar would allow admission for pharmacists "even if they have records of harmful prescription errors or a high number of consumer complaints."
• Policies that undermine payers' ability to audit independent pharmacies suspected of fraud ("Audit Reform" policies).
  • NHCAA supports measures that would "protect the integrity of health care audits by giving auditors more discretion and flexibility to perform their duties." Unfortunately, legislation championed by the independent drugstore lobby (HR 5234, the PBM Audit Reform and Transparency Act of 2010) would instead grant pharmacies (even those with wasteful or abusive practices) an advance notice "heads up" before performing audits.
• 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.

SOURCE Pharmaceutical Care Management Association