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NCPA: Balanced approach needed to thwart Part D fraud

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ALEXANDRIA, Va. — The National Community Pharmacists Association has called on Congress, Medicare and industry stakeholders to strike a balance in stamping out fraud in Medicare Part D while preserving patient access to critical medications.

In comments submitted on Tuesday in conjunction with a House Energy and Commerce subcommittee hearing, titled “Medicare Part D: Measures Needed to Strengthen Program Integrity,” NCPA recommended that the Centers for Medicare & Medicaid Services (CMS) require Part D plan sponsors to report potential fraud and abuse or preventive steps taken by the plan sponsor.

The asociation noted that the Office of Inspector General (OIG) of the Department of Health and Human Services recently suggested such a mandate because the agency determined that under the current voluntary reporting system, less than half of plan sponsors report such information.

NCPA also urged the continuance of current drug utilization review programs, such as for controlled substances, but added that these reviews shouldn’t be expanded to additional drug therapies because it could be unduly burdensome and impact timely care for patients.

In addition, any examination of “questionable pharmacy billing practices” must take into account legitimate patient care circumstances, NCPA noted. For example, a community pharmacy that serves a large number of oncology or pain management practices may dispense more controlled substances than other pharmacies, the association explained.

NCPA also recommended that beneficiary protections must be included in any “lock-in” proposal to restrict certain beneficiaries to a specific pharmacy or prescriber. In virtually all of the 46 state Medicaid lock-in programs, the beneficiary retains the ability to select the in-network prescriber and pharmacy, and without such protections the plan sponsor could assign beneficiaries to a pharmacy in which it has a financial interest, the association said.

“Independent community pharmacists are proud to play a vital role in the Medicare Part D program and have been on the front lines of providing medications, related counseling, and assistance with plans since the inception of the Part D program,” NCPA CEO B. Douglas Hoey said in a statement. “More than any other segment of the pharmacy industry, independent pharmacies are often located in the underserved and rural areas that are home to many Medicare recipients. While NCPA remains supportive of efforts to prevent and reduce fraud, waste and abuse within the Medicare Part D program, they must be delicately balanced with ensuring appropriate patient access to vitally important medications.”


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