Medicare plans to arm itself with broad new powers to better control — and potentially bar — doctors engaged in fraudulent or harmful prescribing, following a series of articles detailing lax oversight in its drug program.
The Centers for Medicare and Medicaid Services described the effort Monday in what's known as a proposed rule, the standard process by which federal agencies make significant changes.
Two of the changes mark a dramatic departure for the agency, which historically has given much higher priority to making medications easily accessible to seniors and the disabled than to weeding out dangerous providers of health care.
For the first time, the agency would have the authority to kick out physicians and other providers who engage in abusive prescribing. It could also take such action if providers' licenses have been suspended or revoked by state regulators or if they were restricted from prescribing painkillers and other controlled substances.
And the agency will tighten a loophole that has allowed doctors to prescribe to patients in the drug program, known as Part D, even when they were not officially enrolled with Medicare. Under the new rules, doctors and other providers must formally enroll if they want to write prescriptions to the 36 million people with Part D coverage. This would require them to verify their credentials and disclose professional discipline and criminal history.
The changes would take effect Jan. 1, 2015. As part of the process, CMS will accept public comments until March 7 and could revise the proposals based on the feedback.
Several of the proposed changes address failings detailed by a ProPublica investigation last year.
In December, NPR and ProPublica ran a story about how Medicare's system of fighting fraud is so convoluted and poorly managed that scams flourish and millions are wasted.
Reporters analyzed Medicare's prescribing data to spot doctors who prescribed in very different ways than their peers — for example, by choosing drugs that were risky or costly, or in ways that suggested fraud.
On Monday, Medicare proposed giving its outside fraud contractor the ability to more easily investigate suspicions of fraud.
Currently, the contractor cannot directly access patient medical charts to assess whether the patient actually saw the doctor or had a condition that warranted the medication. The contractor must go back to the insurers, which then request the records from doctors or pharmacies.
Under the rule change, the contractor would be given the power to access the records directly. The inspector general of the Department of Health and Human Services has repeatedly pressed Medicare to make this change.
In a blog post, Jon Blum, the principal deputy administrator for CMS, said his agency is serious about fighting fraud and abuse in Part D.
"CMS strives to ensure that beneficiaries have the medications they need while at the same time is being vigilant to safeguard the program from inappropriate use," Blum wrote.
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