Part D Program Integrity

Program integrity responsibilities in Medicare Part D are shared by plan  sponsors, CMS’s Center for Program Integrity (CPI) and Center for  Medicare, and CMS’s program integrity contractors. CMS’s Oversight

CMS’s CPI oversees Part D program integrity and coordinates with other  groups within CMS’s Center for Medicare that monitor plan sponsor  compliance with the Part D program. We Identified Multiple Prevention, Detection, and Investigation Practices to Address Prescription Drug Fraud, Waste, and Abuse

We identified a total of 23 practices for addressing prescription drug  fraud, waste, and abuse that fall within one or more of the three  categories based on the Fraud Prevention Framework: (1) prevention,   (2) detection and monitoring, and (3) investigation and prosecution. Investigation and Prosecution

We identified six practices related to the investigation and prosecution of  prescription drug fraud, waste, and abuse, as shown in table 3. Practices  include having investigative staff knowledgeable of prescription drug  schemes and experienced in investigating them, as well as having the  ability to take actions to enforce prescription drug rules. CMS, with Its Contractors, Has Implemented Many Program Integrity Practices, Particularly within the Categories of Detection and Monitoring and Investigation and Prosecution

CMS activities to address prescription drug fraud, waste, and abuse  reflect 14 of the 23 total practices we identified, based on interviews with  officials and review of agency documents. Agency Comments

We provided a draft of this report to the Department of Health and Human  Services (HHS) for comment and HHS provided written comments, which  are reprinted in appendix II. We determined that CMS had implemented a practice if the agency  required or documented at least one activity within that practice, that CMS  planned a practice if documentation or officials described activities as  pilots or in the process of development, and that CMS was not pursuing  practices based on reviews of documentation and interviews with officials.
Why GAO Did This Study

Recent media reports and law enforcement actions have highlighted the problem of prescription drug fraud, waste, and abuse in the United States. Medicare, and the Part D prescription drug benefit, are susceptible to such fraud—a risk made greater by Medicare's size, scope, and complexity. GAO and others have raised questions about CMS's oversight of its activities to address fraud, waste, and abuse in Part D, as well as oversight of the contractors tasked with this work.
GAO examined (1) practices for promoting prescription drug program integrity, and (2) the extent that CMS's oversight of Medicare Part D program integrity, including the program integrity contractors, reflects these practices. To develop a list of practices, GAO interviewed 14 stakeholder groups involved in various aspects of prescription drug program integrity, including provider, beneficiary, and anti-fraud groups; identified and reviewed related documents; and conducted a search of eight bibliographic databases that included peer-reviewed articles and government documents. GAO organized the practices based on the three categories of GAO's Fraud Prevention Framework. To determine how CMS's oversight reflects these practices, GAO analyzed agency documents, such as contracts, manuals, work products, and CMS audits of contractors; and interviewed agency officials.

What GAO Found

GAO identified 23 practices for addressing prescription drug fraud, waste, and abuse that fall within three categories based on GAO's Fraud Prevention Framework—prevention, detection and monitoring, and investigation and prosecution.
The Department of Health and Human Services' (HHS) Centers for Medicare & Medicaid Services' (CMS) activities to address prescription drug fraud, waste, and abuse in the Medicare Part D prescription drug program reflect 14 of these 23 identified practices, some of which are in multiple categories, and the agency plans to implement 3 additional practices.
a practice if documentation or officials described activities as pilots or in the process of development, and that CMS was not pursuing a practice based on reviews of documentation and interviews with officials.
HHS generally agreed with our findings.