Benefit managers use fraud recommendations to slam pharmacists' proposals

In the ongoing war between drug providers, pharmacy benefit managers — the third-party administrators of prescription drug programs — are taking aim at pharmacist- and drugstore-backed legislation they say could increase healthcare fraud.

The Pharmaceutical Care Management Association is touting a new report by the National Health Care Anti-Fraud Association that outlines "seven guiding principles for policymakers" in a post-health reform environment. The PCMA says several current and proposed policies, which are not named in the report, run counter to those principles.

The principles are: 

• Enhancing the sharing of anti-fraud information between private insurers and government programs;
• Increasing data consolidation and real-time data analysis;
• Strengthening pre-payment reviews and audits;
• Allowing public and private health plans to bar or expel providers suspected of perpetrating healthcare fraud;
• Sanctioning healthcare providers who participate in fraud by their respective state licensing boards;
• Making healthcare provider identifier numbers more secure;
• Encouraging investments in innovative healthcare fraud prevention, detection and investigation efforts and programs.

The PCMA says three legislative proposals in particular seem to run counter to these principles. 
• The "Patient Health and Real Medication Access Cost Savings Act of 2009," sponsored by Rep. G. K. Butterfield (D-N.C.), which according to PCMA forces plans to include in their networks pharmacies that have been banned from federal programs. The anti-fraud report says federal proposals that would allow "any willing" licensed pharmacists not convicted of a crime to participate in employer-sponsored plan networks offer a "low standard of admission" that "could allow for the participation in employer networks of pharmacists who have been suspended from government programs."
• The "PBM Audit Reform and Transparency Act of 2010," sponsored by Rep. Anthony Weiner (D-N.Y.), would grant pharmacies an advance notice 'heads up' before performing audits, according to the PCMA. The anti-fraud report warns that "proposed federal and state legislation that would require payers to provide providers advance warning of an audit — even in cases when fraud is suspected — would give suspects time to tamper with evidence and evade authorities altogether."
• Prompt pay laws in the Medicare Part D program that reduce payers’ time to verify pharmacy claims for potential fraud, waste and abuse before payment. The anti-fraud report states that "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."

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