[Report] Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse (OEI-03-13-00030) 03-03-2014

Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse (OEI-03-13-00030) 03-03-2014.

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More than half of Part D plan sponsors did not report data on potential fraud and abuse between 2010 and 2012. Of those sponsors that did report data, more than one-third did not identify any incidents for at least one of their reporting years. In total, sponsors reported identifying 64,135 incidents of potential fraud and abuse between 2010 and 2012. Sponsors’ identification of such incidents varied significantly, from 0 to almost 14,000 incidents a year.

CMS requires sponsors to conduct inquiries and implement corrective actions in response to incidents of potential fraud and abuse; however, 28 percent of Part D plan sponsors reported performing none of these actions between 2010 and 2012. Although CMS reported that it conducted basic summary analyses of the data on potential fraud and abuse, it did not perform quality assurance checks on the data or use them to monitor or oversee the Part D program.
WHAT WE RECOMMEND
We recommend that CMS (1) amend regulations to require sponsors to report to CMS their identification of and response to potential fraud and abuse; (2) provide sponsors with specific guidelines on how to define and count incidents, related inquiries, and corrective actions; (3) review data to determine why certain sponsors reported especially high or low numbers of incidents, related inquiries, and corrective actions; and (4) share sponsors’ data on potential fraud and abuse with all sponsors and law enforcement. CMS did not concur with the first recommendation, partially concurred with the second and fourth recommendations, and concurred with the third recommendation.

 

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