Medicare Part D paid $32 million in 2012 for HIV drugs for beneficiaries with questionable utilization patterns, according to an HHS Office of Inspector General report.
The beneficiaries in question had no indication of HIV in their Medicare histories, received an extensive dose or supply, received HIV drugs from a high number of prescribers or pharmacies, or received medications that shouldn't be used in combination with each other. HIV drugs are vulnerable to fraud, waste and abuse because they can be expensive and can also have psychoactive effects, according to the OIG. In 2012, Medicare Part D paid a total of $2.8 billion for HIV drugs.
Although some of the questionable utilization pinpointed by the OIG's analysis of prescription drug event records for HIV drugs could be legitimate, the agency has determined these patterns need further examination. "These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market," the report states. "They may also indicate that a pharmacy is billing for drugs that a beneficiary never received or that a beneficiary's identification number was stolen."
The OIG has recommended that CMS expand the drug utilization review programs administered by the health insurers the agency contracts with to provide Part D prescription drug coverage. Additionally, according to the report, CMS should expand its overutilization monitoring system to include additional drugs prone to fraud, waste and abuse; expand insurers' use of beneficiary specific controls; restrict certain patients to a limited number of pharmacies or prescribers; limit certain individuals' ability to change coverage plans; increase monitoring of beneficiaries' utilization patterns; and follow up on questionable patterns.