Not only are pharmacies and those who prescribe Part D drugs increasingly becoming targets for whistleblowers with False Claims Act suits for kickbacks and other fraud-based conduct, they also need to be concerned with Medicare Part D insurers, who monitor pharmacies for abuse On May 19, 2014, as well as CMS (Centers for Medicare & Medicaid Services) which issued a final rule revising the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations for Contract Year 2015 (CMS-4159-F), aimed primarily at combating fraud and abuse in Part D.

               Of significance is that the final regulation implements the Affordable Care Act requirement that MA plans and Part D sponsors actually report and return identified Medicare overpayments.  The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must actually report and return overpayments.

               The rule also expands health promotion and incentives for efficient use of health care resources and requires price transparency for Part D plans and network pharmacies.  Another provision requires that physicians, and other professionals who order durable medical equipment and supplies or certify home health care for beneficiaries, be enrolled in Medicare.  Such enrollment requirement can be extended to those who order covered Part D drugs, among other things.

               Notably, the rule adds authority to revoke a physician’s or eligible professional’s Medicare enrollment under certain circumstances of abusive prescribing practices and patterns.  The focus of providing CMS the authority to revoke such prescribers’ Medicare enrollment is designed to help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse.

Most of the provisions of the final rule will become effective for the 2015 contract year operations, and can be accessed in the full rule at: