Department of Health and Human Services 
OFFICE OF 
 
  INSPECTOR GENERAL 
 
 
 
 
 
 
P W  
RESCRIBERS  ITH  
 
Q   P  
UESTIONABLE  ATTERNS
 
  M P D  
IN  EDICARE  ART   
 
 
Daniel R. Levinson  
Inspector General 
 
June 2013 
OEI-02-09-00603   
PRESCRIBERS WITH QUESTIONABLE PATTERNS IN MEDICARE PART D  
OEI-02-09-00603 
 
 
WHY WE DID THIS STUDY 
 
Under the Medicare Part D program, the Centers for Medicare & Medicaid Services 
(CMS) contracts with private insurance companies, known as sponsors, to provide 
prescription drug coverage to beneficiaries who choose to enroll.  In recent years, 
prescription drug abuse has emerged as a serious and growing problem.  The Centers for 
Disease Control and Prevention has characterized prescription drug abuse as an epidemic.  
With the rise in prescription drug abuse, concerns about Medicare fraud, particularly 
prescriber fraud, have increased.  
 
HOW WE DID THIS STUDY 
 
We based this study on an analysis of Prescription Drug Event records.  Sponsors submit 
these records to CMS for each drug dispensed to beneficiaries enrolled in their plans.  
Each record contains information about the pharmacy, prescriber, beneficiary, and drug.  
We analyzed all of the records for drugs billed in 2009.  We developed five measures to 
describe Part D prescribing patterns and to identify general-care physicians with 
questionable patterns. 
 
WHAT WE FOUND 
 
Over 1 million individual prescribers ordered drugs paid by Part D in 2009.  Prescribing 
patterns varied widely by specialty.  Over 700 general-care physicians had questionable 
prescribing patterns.  Each of these physicians prescribed extremely high amounts for at 
least one of the five measures we developed.  For example, many of these physicians 
prescribed extremely high numbers of prescriptions per beneficiary, which may indicate 
that these prescriptions are medically unnecessary.  Moreover, more than half of the 
736 general-care physicians with questionable prescribing patterns ordered extremely 
high percentages of Schedule II or III drugs, which have potential for addiction and 
abuse.  Although some of this prescribing may be appropriate, such questionable patterns 
warrant further scrutiny.   
 
WHAT WE RECOMMEND 
 
These findings show the need for increased oversight of Part D.  We recommend that 
CMS:  (1) instruct the Medicare Drug Integrity Contractor to expand its analysis of 
prescribers, (2) provide sponsors with additional guidance on monitoring prescribing 
patterns, (3) provide education and training for prescribers, and (4) follow up on 
prescribers with questionable prescribing patterns.  CMS concurred with all four 
recommendations.   
 
   
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................5 
Findings...................................................................................................... 11 
Over 1 million prescribers ordered drugs paid for by Part D  
in 2009 ........................................................................................... 11 
Prescribing patterns varied widely by specialty.............................12 
Over 700 general-care physicians had questionable prescribing 
patterns ...........................................................................................15 
Conclusion and Recommendations ............................................................19 
Agency Comments and Office of Inspector General Response... ..21 
Appendixes ................................................................................................22 
A:  Specialties of Part D Prescribers ..............................................22 
B:  Part D Prescribing Patterns by Specialty .................................23 
C:  Agency Comments ...................................................................24 
Acknowledgments......................................................................................28 
 
   
OBJECTIVES 
1.  To describe Medicare Part D prescribing patterns.  
2.  To determine how Part D prescribing patterns differ by prescribers 
specialties. 
3.  To determine the extent to which general-care physicians had 
questionable Part D prescribing patterns in 2009. 
BACKGROUND 
The Medicare Part D program provides an optional prescription drug benefit 
to Medicare beneficiaries.1  The Centers for Medicare & Medicaid Services 
(CMS) contracts with private insurance companies, known as sponsors, to 
provide drug coverage to beneficiaries who choose to enroll.  In 2011, 
approximately 36 million beneficiaries were enrolled.2 
Prescription drug abuse is a serious and growing problem.  The Centers 
for Disease Control and Prevention (CDC) has characterized prescription 
drug abuse as an epidemic.  In 2010, approximately 7 million people in the 
United States were misusing prescription drugs.3  Moreover, overdoses of 
prescription painkillerscalled opioidsare among the leading causes of 
accidental death in the United States.4 
With the rise in prescription drug abuse, concerns about Medicare fraud, 
particularly prescriber fraud, have increased.  A number of recent 
convictions have involved prescriber fraud.  In one case, the owner of a 
pain clinic and a nurse practitioner prescribed large quantities of the 
painkiller oxycodone to patients without medical need, four of whom 
died.5  In a similar case, a physician knowingly allowed nonmedical 
personnel to prescribe commonly abused painkillers, such as oxycodone, 
 
1 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003,  
P.L. 108-173. 
2 The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary 
Medical Insurance Trust Funds, 2012 Annual Report of the Boards of Trustees of the 
Federal Hospital Insurance and Federal Supplementary Medicare Insurance Trust 
Funds, p. 10.  Accessed at http://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf on  
July 6, 2012.   
3 National Institute on Drug Abuse, Topics in Brief:  Prescription Drug Abuse,  
December 2011.  Accessed at http://www.drugabuse.gov/publications/topics-in-
brief/prescription-drug-abuse on September 18, 2012. 
4 CDC, Unintentional Drug Poisonings in the United States, July 2010.   
5 Federal Bureau of Investigation (FBI), Owner of Chantilly Pain Clinic Convicted of 
Drug Trafficking, Fraud Charges, August 3, 2012.  Accessed at 
http://www.fbi.gov/washingtondc/press-releases/2012/owner-of-chantilly-pain-clinic-
convicted-of-drug-trafficking-fraud-charges on September 11, 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  1 
   
morphine, and hydrocodone, to Medicare beneficiaries by using blank, 
presigned prescription forms.6  In a third case, a physician wrote medically 
unnecessary pain prescriptions for individuals who illegally distributed 
them.7  
Despite these concerns, little information has been available about Part D 
prescribing patterns.  Data about typical prescribing patterns and 
prescribers with questionable patterns are important first steps in detecting 
fraud, waste, and abuse.   
This report is part of a larger body of work examining Part D billing.8  
Another report identified pharmacies with questionable billing in 2009.9  
A third report identified inappropriate Part D payments for Schedule II 
drugs billed as refills.10  A fourth report determines whether Medicare  
Part D paid for drugs ordered by individuals who do not have the authority 
to prescribe.11  In addition, a recent analysis of Part D claims by 
ProPublica found that some prescribers ordered large quantities of drugs 
that are potentially harmful, disorienting, or addictive.12  
Prescription Drugs 
Medicare Part D covers prescription drugs that meet certain requirements 
and are used for medically accepted indications.13  CMS considers a drug 
to be prescription if the Food and Drug Administration has determined it 
must be labeled Rx only, which means it cannot be dispensed without a 
prescription from a practitioner who is licensed to prescribe such drugs.14  
 
6 FBI, Palmetto Physician Pleads Guilty To Illegal Prescription Drug and Medicare 
Fraud Conspiracies, March 18, 2010.  Accessed at http://www.fbi.gov/tampa/press-
releases/2010/ta031810.htm on July 2, 2012. 
7 U.S. Department of Justice, Operation Oxyclean:  Independence Physician Pleads 
Guilty To $1 Million Drug-Trafficking Conspiracy.  Accessed at 
http://www.justice.gov/usao/mow/news2011/baker.ple.html on July 6, 2011. 
8 All four reports are part of the Health Care Fraud Prevention and Enforcement Action Team 
Initiative (HEAT), which focuses on detecting health care fraud through innovative data 
analysis and enhanced cooperation among the Department of Justice, Office of Inspector 
General (OIG), and CMS. 
9 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, May 
2012. 
10 OIG, Inappropriate Medicare Part D Payments for Schedule II Drugs Billed As Refills, 
OEI-02-09-00605, September 2012. 
11 OIG, Medicare Part:  Drugs Ordered by Individuals Without Prescribing Authority, 
OEI-02-09-00608, June 2013. 
12 Tracy Weber, Charles Ornstein, and Jennifer LaFleur, Medicare Drug Program Fails to 
Monitor Prescribers, Putting Seniors and Disabled at Risk, ProPublica, May 11, 2013.  
Accessed at http://www.propublica.org/article/part-d-prescriber-checkup-mainbar on  
May 15, 2013. 
13 42 U.S.C.  1860D-2(e)(1).   
14 CMS, Medicare Prescription Drug Benefit Manual, Chapter 6, Part D Drugs and 
Drug Formulary Requirements,  10, February 2010.  Also see 21 U.S.C.  353(b)(1). 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  2 
   
The types of practitioners that are licensed to prescribe drugs are 
determined by State law.   
The Drug Enforcement Administration (DEA) regulates certain drugs that 
have potential for abuse and dependence, called controlled substances.  
These drugs are divided into five schedules.  Schedule II drugs have the 
highest potential for abuse of any prescription drugs legally available in 
the United States.15  They include stimulants and narcotics commonly used 
to relieve pain, such as oxycodone and morphine.  Schedule III drugs, 
such as hydrocodone with acetaminophen, also have potential for abuse.  
DEA requires all practitioners who handle controlled substances to register 
with the agency.16  
Prescriber Fraud and Abuse 
A number of fraud schemes in Part D involve prescribers.17  Notably, 
prescribers sometimes operate pill mills or accept kickbacks.  To operate 
a pill mill, a prescriber writes large quantities of prescriptions, usually for 
controlled substances that are not medically necessary and are often for 
people who are not their patients.  A kickback is paid to a prescriber to 
write an unnecessary prescription that is then billed to Medicare.  In other 
schemes, prescribers prescription pads or provider identification numbers 
are stolen or sold by prescribers; these items then are used to write illegal 
prescriptions or to submit claims to Medicare. 
Detecting and Deterring Part D Fraud and Abuse 
CMS relies on sponsors to help safeguard Part D from fraud and abuse. 
CMS requires sponsors to have compliance plans that contain measures to 
detect, prevent, and correct fraud, waste, and abuse.18  CMS recommends 
that sponsors use data analysis as a part of these plans.19  Specifically, it 
recommends that sponsors develop indicators and establish baseline data 
so that they can recognize abnormalities and changes in prescribing 
patterns. 
 
15 Schedule I drugs currently have no accepted medical use in the United States.  They 
include drugs such as heroin.   
16 DEA registration grants prescribers Federal authority to handle certain schedules of 
controlled substances.  See 21 CFR  1301.11. 
17 CMS, Prescription Drug Benefit Manual, Chapter 9, Part D Program to Control 
Fraud, Waste and Abuse:  Use of Data Analysis for Fraud, Waste and Abuse Prevention 
and Detection,  70.1.4, April 2006.  Accessed at 
http://www.cms.gov/PrescriptionDrugCovContra/Downloads/PDBManual_Chapter9_FW
A.pdf on September 12, 2012. 
18 42 CFR  423.504(b)(4)(vi). 
19 CMS, Prescription Drug Benefit Manual, Chapter 9, Compliance Program Guidelines, 
 50.6.9, July 2012.  Accessed at http://www.cms.gov/Medicare/Prescription-Drug-
Coverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf on September 12, 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  3 
   
Sponsors are also required to have a Drug Utilization Review program to 
assist in preventing overutilization of prescribed medications.20  CMS 
recently issued guidance recommending that sponsors use data analysis as 
part of their Drug Utilization Review programs to identify beneficiaries 
who may be overutilizing opioids.  Opioids include Schedule II controlled 
substances, such as oxycodone, morphine, and fentanyl.  CMS also 
recommended that sponsors communicate with prescribers to ascertain the 
medical necessity of these drugs.  
Additionally, CMS contracts with a Medicare Drug Integrity Contractor 
(MEDIC) to detect and prevent fraud, waste, and abuse.  Its 
responsibilities include identifying and investigating potential Parts C  
and D fraud and abuse, referring cases to OIG, and fulfilling requests for 
information from law enforcement.21  The MEDIC is required to identify 
potential fraud and abuse through external sources, such as tips, as well as 
proactive methods, such as data analysis.22   
CMS is responsible for the oversight of sponsors and the MEDIC.  CMS 
conducts a number of different audits for sponsors, including onsite audits 
of their compliance plans.23  During these audits, CMS assesses the 
effectiveness of sponsors fraud and abuse programs.  CMS evaluates the 
MEDICs performance annually. 
Related Work 
A recent OIG report found that 2,637 retail pharmacies had questionable 
billing in 2009.24  These pharmacies had extremely high billing for at least 
one of the eight measures we developed.  For example, many pharmacies 
billed extremely high dollar amounts or numbers of prescriptions per 
beneficiary or per prescriber, which could mean that a pharmacy is billing 
for drugs that are not medically necessary or were never provided to the 
beneficiary.  Among other things, the report recommended that CMS 
strengthen its monitoring of pharmacies, provide additional guidance to 
 
20 CMS, Announcement of Calendar Year (CY) 2013 Medicare Advantage Capitation 
Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter,  
April 2, 2012.  Accessed at http://www.cms.gov/Medicare/Health-
Plans/HealthPlansGenInfo/Downloads/2013-Call-Letter.pdf on October 4, 2012.  Also 
see CMS, Supplemental Guidance Related to Improving Drug Utilization Review 
Controls in Part D, August 31, 2012. 
21 CMS, MEDIC Statement of Work, July 2009. 
22 For more information on the responsibilities of the National Benefit Integrity MEDIC, 
see OIG, MEDIC Benefit Integrity Activities in Medicare Parts C and D, OEI-03-11-
00310, January 2013.  
23 For more information on CMS audits, see OIG, Audits of Medicare Prescription Drug 
Plan Sponsors, OEI-03-09-00330, December 2011. 
24 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600,  
May 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  4 
   
sponsors on monitoring pharmacy billing, and further strengthen its 
compliance plan audits.  CMS concurred with these recommendations. 
Another recent OIG report found that Medicare Part D inappropriately 
paid $25 million for Schedule II drugs billed as refills in 2009.25  Sponsors 
should not have paid for any of these drugs because Federal law prohibits 
the refilling of Schedule II controlled substances without a new 
prescription.26  Also, three-quarters of Part D sponsors paid for Schedule II 
drugs billed as refills, indicating that many sponsors do not have adequate 
controls to prevent these refills.  Among other things, the report 
recommended that CMS issue guidance to sponsors to prevent billing of 
Schedule II refills and to exclude Schedule II refills when calculating 
payments to sponsors. 
Another OIG report found that Medicare Part D paid $1.2 billion in 2007 
for drugs with invalid prescriber identifiers (the identifiers had either 
never been assigned or had been retired).27  The report recommended that 
CMS conduct periodic reviews to ensure the validity of prescriber 
identifiers and require Part D plans to institute procedures to identify and 
review records containing invalid prescriber identifiers.  
An additional OIG report found barriers to the MEDICs benefit integrity 
efforts.28  These barriers included problems in the sharing of information 
and recovering inappropriate payments.  The report also found that only a 
small percentage of the MEDICs investigations and case referrals resulted 
from proactive data analysis.  In the 1-year study period, the MEDIC 
initiated just 209 Part D investigations from proactive methods, such as 
data analysis.  
METHODOLOGY 
We based this study on an analysis of Prescription Drug Event (PDE) 
records from 2009, which we collected to undertake this body of work.  
Sponsors submit these records to CMS for each drug dispensed to 
beneficiaries enrolled in their plans.  Each record contains information 
about the beneficiary, pharmacy, prescriber, and drug.  We matched these 
 
25 OIG, Inappropriate Part D Payments for Schedule II Drugs Billed as Refills,  
OEI-02-09-00605, September 2012. 
26 Federal law permits partial refills under certain circumstances.  It is possible some of 
these drugs may have been inaccurately billed as refills when they were partial fills.   
27 OIG, Invalid Prescriber Identifiers on Medicare Part D Claims, OEI-03-09-00140,  
June 2010. 
28 OIG, MEDIC Benefit Integrity Activities in Medicare Parts C and D,  
OEI-03-11-00310, January 2013. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  5 
   
records to data from the National Plan and Provider Enumeration System 
(NPPES) to obtain descriptive information about the prescribers.   
Sponsors are required to certify the accuracy, completeness, and 
truthfulness of their PDE data.29  Beginning in January 2012, they are also 
required to ensure that the prescriber identifiers on the PDE records are 
active and valid, meaning that they are currently assigned to a health care 
provider. 30   
PDE Data 
We obtained all PDE records for covered Part D drugs with dates of 
service from January 1 to December 31, 2009.  This amounted to  
1,070,149,994 PDE records.   
For each PDE record, we identified the identification number of the 
prescriber, which was generally a National Provider Identifier (NPI).31  
NPIs are assigned to many different types of health care providers.  
Having an NPI does not mean that an individual has the authority to 
prescribe drugs.  For records that used other types of prescriber 
identification numbers, we used a crosswalk developed by OIG analysts to 
identify the prescribers NPI.32   
We matched each NPI to the NPPES to determine which PDE records 
were prescribed by individuals, as opposed to organizations (e.g., hospitals 
or group practices).  We focused our review on individual prescribers 
because organizations may be associated with multiple prescribers.  We 
identified 1,102,275 individual prescribers who were associated with 
1,026,983,870 PDE records.  These records represent 96 percent of all 
PDE records in 2009.   
Using the National Drug Code (NDC) on the PDE record, we matched the 
PDE records to data from First DataBank.  First DataBank contains 
information about each drug, such as the drug name and whether the drug 
 
29 42 CFR  423.505(k). 
30 Sponsors must also confirm that any controlled substances are consistent with the 
schedule of drugs that the provider is allowed to handle.  CMS, Announcement of 
Calendar Year (CY) 2012 Medicare Advantage Capitation Rates and Medicare 
Advantage and Part D Payment Policies and Final Call Letter, April 4, 2011. 
31 PDE records allow four types of prescriber identification numbers:  NPIs, DEA 
numbers, State license numbers, and Unique [Physician] Identification Numbers (UPIN).  
32 To develop this crosswalk, we used information from the Services Tracking, Analysis, 
and Reporting System (known as STARS), the DEA database, and the NPPES.  We were able 
to identify valid NPIs for 97 percent of the PDE records.  The remaining 3 percent had 
missing identifiers or were billed with identifiers that we could not link to a valid NPI. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  6 
   
is brand-name or generic.33  It also indicates whether a drug is a controlled 
substance and, if so, which schedule the drug is on (Schedule II or III).34   
Prescribing Measures  
We used five measures to describe Part D prescribing patterns.  We 
developed these measures on the basis of the results of past OIG analyses 
and fraud investigations of Part D billing, as well as input from CMS staff.  
We calculated the five measures for each individual prescriber, then 
calculated the national average for each measure. 
The five measures are:   
(1) average number of prescriptions per beneficiary,35  
(2) total number of pharmacies associated with each prescriber,  
(3) percentage of prescriptions that were for Schedule II drugs,  
(4) percentage of prescriptions that were for Schedule III drugs, and 
(5) percentage of prescriptions that were for brand-name drugs.  
We calculated the total number of beneficiaries that each prescriber 
ordered drugs for by using the Health Insurance Claim Number (HICN) on 
the PDE record.  We calculated the total number of pharmacies by using 
the NPI for each pharmacy or, if it was unavailable, the identification 
number for the pharmacy on the PDE record.36  For the purposes of this 
report, we use the term prescription to mean one PDE record. 
Analysis by Prescriber Specialty 
To identify the specialty for each prescriber, we matched the NPIs to the 
NPPES.  The NPPES contains information reported by each prescriber, 
such as his or her specialty, address, and professional credentials, such as 
 
33 First DataBank determines whether a drug is brand-name or generic based on the 
drugs name. 
34 A total of 0.002 percent of the PDE records had an NDC that did not match to First 
DataBank.  We did not include these records in the analysis on Schedule II, Schedule III, 
or brand-name drugs. 
35 This measure represents the average number of prescriptions one prescriber ordered per 
beneficiary.  It does not represent the average number of prescriptions that each 
beneficiary received because a beneficiary can receive prescriptions from multiple 
prescribers.  
36 To identify the number of pharmacies, we used the same method as in an earlier report.  
See OIG, Retail Pharmacies With Questionable Part D Billing (OEI-02-09-00600),  
May 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  7 
   
M.D. or R.N.  Providers report this information to CMS and must ensure 
that it is updated and accurate.37   
We identified each prescribers specialty based on the primary taxonomy 
code that he or she reported in the NPPES.  The taxonomy code indicates 
a providers specialty and subspecialty, if any.  For example, it may 
indicate that a prescriber is a family-medicine physician specializing in 
geriatric medicine.   
We then grouped the taxonomy codes for similar specialties.  For 
example, we grouped all of the nurse practitioners together and all of the 
dentists together.  We considered general-care physicians to be general 
practitioners, family practitioners, and internal medicine practitioners with 
no specialization or a specialization in adults or geriatrics.38  We 
calculated each groups average for the five measures listed above.39   
Identification of General-Care Physicians With Questionable 
Prescribing Patterns 
To identify prescribers with questionable patterns, we focused our analysis 
on general-care physicians in nonrural areas.  We focused on general-care 
physicians because they are the most common type of Part D prescriber 
and they prescribed more than half of all Part D prescriptions in 2009.  We 
focused on physicians who were located in nonrural areas because those in 
very rural areas may have different prescribing patterns due to their 
location.  For example, these physicians may order unusually high 
numbers of drugs per beneficiary because there are fewer physicians or 
specialists in their areas.  We considered physicians who were not located 
in a Core Base Statistical Area (CBSA)a region around an urban center 
that has at least 10,000 peopleto be in very rural areas.40  In total, we 
based this analysis on 86,818 general-care physicians and 
540,581,871 PDE records.41 
 
37 When applying for an NPI, the provider signs a certification that the information is 
correct and that he or she agrees to provide notification of any changes within 30 days.  
CMS, National Provider Identifier (NPI) Application/Update Form, November 2008.  
Accessed at https://www.cms.gov/Medicare/CMS-Forms/CMS-
Forms/Downloads/CMS10114.pdf on June 5, 2012. 
38 We reviewed each specialtys prescribing patterns to ensure that they were similar to 
the other specialties and that we could group them together.  
39 For this analysis, we included the 22 specialty groups that each had more than  
3 million PDE records.     
40 U.S. Census Bureau, Metropolitan and Micropolitan Statistical Areas.  Accessed at 
http://www.census.gov/population/www/metroareas/aboutmetro.html on March 3, 2011.  
41 For this analysis, we included general-care physicians who were associated with 100 or 
more PDE records that amounted to $100,000 or more.  For the analysis of Schedule II 
and III drugs, we included prescribers associated with 100 or more PDE records for those 
drugs.  
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  8 
   
To identify the general-care physicians who were very extreme outliers 
compared to their peers, we took several steps.  We first used a standard 
technique for identifying outliers, known as the Tukey method.42  Using 
this method, we identified 2,248 general-care physicians who were 
outliers (i.e., above the 75th percentile plus 3 times the interquartile range) 
on one or more of the five measures we reviewed.  In analyzing these 
physicians prescribing patterns further, we identified the prescribers who 
were even more extreme outliers.  These outliers corresponded to a 
threshold of at least the 75th percentile plus 4.5 times the interquartile 
range for each measure.  
We considered general-care physicians who exceeded one or more of 
these thresholds to have questionable prescribing patterns.  Some of their 
prescribing may have been appropriate.  However, prescribing high 
amounts on any of these measures may indicate that a physician is 
prescribing drugs which are not medically necessary or that he or she has 
an inappropriate incentive, such as a kickback, to order certain drugs.  It 
may also indicate that the prescribers identification number or 
prescription pad has been sold or stolen.  We calculated the total amount 
Medicare paid for drugs prescribed by these general-care physicians.43 
We then determined the extent to which prescribers with questionable 
prescribing patterns had certain characteristics in common.  We identified 
each prescribers CBSA to determine whether they were concentrated in 
certain areas.  We also determined which drugs were most commonly 
ordered by prescribers with questionable patterns.   
Lastly, we determined whether the general-care physicians with 
questionable patterns were associated with any of the 2,637 retail 
pharmacies with questionable billing that we identified in an earlier 
report.44  We considered a physician to be associated with a pharmacy if 
the pharmacy billed at least 25 percent of the cost of all the drugs that the 
physician prescribed in 2009.  
 
42 See J.W. Tukey, Exploratory Data Analysis.  Addison-Wesley, 1977.  The Tukey 
method traditionally sets the threshold at the 75th percentile plus 1.5 or 3 times the 
interquartile range.  The interquartile range is calculated by subtracting the value at the 
25th percentile from the value at the 75th percentile. 
43 We used three fields on the PDE records to calculate Part D payments:  the ingredient 
cost, dispensing fee, and sales tax.  This includes the amount paid by sponsors, the 
Government, and by, or on behalf of, beneficiaries. 
44 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600,  
May 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  9 
   
Limitations 
We designed this study to identify prescribers who warrant further 
scrutiny.  None of the measures we analyzed independently confirm that a 
particular prescriber is engaging in fraudulent or abusive practices.   
We did not independently verify the accuracy of the PDE records or the 
data from the NPPES.  In particular, we did not verify the information 
about prescribers specialties that they reported in the NPPES.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  10 
   
FINDINGS 
Over 1 million prescribers ordered drugs paid for by 
Part D in 2009 
A total of 1.1 million prescribers ordered Part D drugs for Medicare 
beneficiaries in 2009.  These prescribers included many specialties, such 
as general-care physicians, dentists, and nurse practitioners. 45 These 
individuals ordered over 1 billion prescriptions during the year.  In total, 
Medicare paid $70.7 billion for these prescriptions.46  On average, these 
1.1 million prescribers each ordered Part D prescriptions costing $64,102.  
Prescribers typically did not order drugs for a very large number of 
beneficiaries, nor did they order many drugs per beneficiary during the 
year.  On average, each prescriber ordered prescriptions for  
80 beneficiaries and averaged 6 prescriptions per beneficiary.  
Interestingly, more than half of the prescribers ordered fewer than 100 Part 
D prescriptions each during the year.  Further, on average, prescribers 
ordered drugs that were dispensed at 32 pharmacies.  Half the prescribers 
ordered drugs that were dispensed at 17 or fewer pharmacies.   
Two-thirds of prescribers ordered Schedule II or III drugs.  Schedule II 
drugs are controlled substances that have potential for abuse and may lead 
to severe psychological or physical addiction.  They include drugs such as 
oxycodone and morphine.  On average, 4 percent of the prescriptions from 
each prescriber were for Schedule II drugs.  Schedule III drugs also have 
potential for abuse and include anabolic steroids, hydrocodone with 
codeine, and barbiturates.  On average, 7 percent of the prescriptions from 
each prescriber were for Schedule III drugs.   
On average, about a quarter of the prescriptions ordered by each prescriber 
were for brand-name drugs.  Interestingly, 16 percent of prescribers did 
not order any brand-name drugs, while 10 percent of prescribers ordered 
60 percent or more of their prescriptions as brand-name.  Brand-name 
drugs tend to be more expensive than generic drugs.  See Table 1 for more 
information on prescribing patterns. 
 
   
 
45 For the purposes of this report, general-care physicians include general practitioners, 
family practitioners, and internal medicine practitioners with no specialization or a 
specialization in adults or geriatrics.   
46 This includes the amount paid by sponsors, the Government, and by, or on behalf of, 
beneficiaries. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  11 
   
Table 1:  Part D Prescribing Patterns for All Prescribers, 2009  
 
10th  50th  90th 
National Average 
Percentile  Percentile  Percentile 
Average Number of Prescriptions per 
6  1  3  16 
Beneficiary  
Number of Pharmacies Associated 
32  1  17  85 
With Each Prescriber  
Percentage of Schedule II Drugs  4%  0%  0%  10% 
Percentage of Schedule III Drugs  7%  0%  1%  23% 
Percentage of Brand-Name Drugs  27%  0%  25%  60% 
Note:  For the purposes of this report, we considered a prescription to be one PDE record.  
Source:  OIG analysis of Part D data, 2012.  
 
 
Prescribing patterns varied widely by specialty 
General-care physicians were the most common type of prescriber and 
ordered the majority of Part D prescriptions.  General-care physicians 
accounted for 20 percent of all prescribers in 2009 and ordered two-thirds 
of all of Part D prescriptions in 2009.  Dentists were the second most 
common type of prescriber, but were responsible for just 1 percent of  
Part D prescriptions overall.  Nurse practitioners and physicians assistants 
were also common prescribers; together they represented 11 percent of 
prescribers and were responsible for a little less than 6 percent of the  
Part D prescriptions.  See Table 2 for the most common specialties.  See 
Appendix A for a more complete list. 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  12 
   
Table 2:  Most Common Specialties of Part D Prescribers 
Percentage of All  Percentage of All 
Specialty  
Prescribers  Prescriptions 
General Care   20%  65% 
Dentistry  14%  1% 
Nurse Practitioners  7%*  3% 
Physician Assistants  5%  2% 
Emergency Medicine   4%  1% 
Psychiatry  4%  3% 
Obstetrics and Gynecology  3%  1% 
Surgery  3%  <1% 
Cardiology  2%  5% 
*The percentages of prescribers and prescriptions for nurse practitioners and physician assistants do not sum 
to 11 percent and 6 percent, respectively, because of rounding.  
Note:  For the purposes of this report, we considered a prescription to be one PDE record.  
Source:  OIG analysis of Part D data, 2012.  
 
General-care physicians ordered more prescriptions per beneficiary than 
other specialties.  Overall, general-care physicians ordered an average of 
13 Part D prescriptions per beneficiary, which is more than double the 
national average of 6.  Other specialties averaged fewer.  For example, 
infectious disease specialists ordered 
Table 3:  Specialties With the 
an average of 11 prescriptions per  Highest Average Number of 
beneficiary and nephrologists ordered  Prescriptions per Beneficiary 
an average of 10.  (See Table 3.)  In 
Specialty  Average  
contrast, emergency medicine 
specialists ordered an average of two 
General Care   13 
prescriptions per beneficiary.  See 
Infectious Disease  11 
Appendix B for more information on 
Nephrology  10 
prescribing patterns by specialty. 
Note:  For the purposes of this report, we 
 Specialties also differed in the  considered a prescription to be one PDE record. 
Source:  OIG analysis of Part D data, 2012.  
number of pharmacies that filled each 
prescribers orders.  Cardiologists, endocrinologists, and rheumatologists 
had the highest number of pharmacies that filled the drugs they ordered; 
each had an average of more than 80 pharmacies per prescriber.  An 
average of 52 pharmacies filled the drugs ordered by each general-care 
physician.  In contrast, dentists and nurse practitioners had fewer 
pharmacies that filled their prescriptions, averaging 12 and 23, 
respectively.  
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  13 
   
Furthermore, specialties varied in their prescribing of controlled 
substances.  A few specialties were more likely than others to order higher 
percentages of Schedule II or Schedule III drugs.  On average, 14 percent 
of the prescriptions ordered by physical medicine and rehabilitation 
specialists were for Schedule II drugs.  Surgeons and anesthesiologists 
were next, with 11 percent of their prescriptions being for Schedule II 
drugs.  (See Table 4.)  General-care 
physicians were less likely to order  Table 4:  Specialties With the 
Schedule II drugs.  On average, 2  Highest Average Percentage of 
percent of the prescriptions ordered by  Schedule II Drugs 
general-care physicians were for 
Specialty  Average 
Schedule II drugs.  Some specialties 
rarely prescribed Schedule II drugs;  Physical Medicine and 
14% 
cardiologists and endocrinologists  Rehabilitation 
averaged a little more than 0.3 percent 
Surgery   11% 
each for their prescriptions. 
Anesthesiology   11% 
The specialties most likely to prescribe 
Note:  For the purposes of this report, we 
Schedule III drugs were surgeons,  considered a prescription to be one PDE record.  
Source:  OIG analysis of Part D data, 2012.  
emergency medicine specialists, and 
dentists.  On average, more than 14 percent of the prescriptions ordered by 
prescribers in each of these specialties were for Schedule III drugs.  In 
contrast, 3 percent of the prescriptions ordered by general-care physicians 
were for Schedule III drugs.  A few specialties, including cardiologists and 
gastroenterologists, rarely prescribed Schedule III drugs. 
Lastly, some specialties were much more likely than others to order 
brand-name drugs.  Ophthalmologists, pulmonologists, and 
endocrinologists commonly ordered brand-name drugs.  More than half 
the prescriptions ordered by prescribers in these specialties were for 
brand-name drugs, on average.  In contrast, 28 percent of the prescriptions 
ordered by general-care physicians were for brand-name drugs.  Dentists 
prescribed only an average of 9 percent brand-name drugs.  These 
differences may be due to the availability of generic equivalents for the 
drugs commonly used by these specialties.  
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  14 
   
Over 700 general-care physicians had questionable 
prescribing patterns 
In total, 2,248 general-care physicians were outliers on one or more of the 
five measures we reviewed.47  In analyzing these physicians prescribing 
patterns further, we identified 736 who were very extreme outliers; we 
considered these physicians to have questionable prescribing patterns.  Each 
of these physicians prescribed extremely high amounts for at least one of 
the five measures we developed.  (See Table 5.)  Medicare paid  
$352 million for the Part D drugs that these physicians ordered.  While 
some of this prescribing may be appropriate, physicians with such 
questionable prescribing patterns warrant further scrutiny.   
These 736 physicians were located throughout the nation.  Los Angeles and 
New York had the greatest numbers, with 34 and 32 physicians, 
respectively.  Philadelphia (22), Tampa (19), and Detroit (15) had the next-
largest numbers. 
 
 
Table 5:  General-Care Physicians Who Prescribed Extremely High Amounts by 
Measure, 2009 
Number of  
Threshold for 
National  General-Care 
Extremely 
Average for  Physicians  
High Amounts 
General- That 
for General-
Care  Prescribed 
Care 
Physicians  Extremely 
Physicians 
High Amounts 
 
Average Number of Prescriptions per Beneficiary  13  71  108 
Number of Pharmacies Associated With Each Prescriber  52  342  35 
Percentage of Schedule II Drugs  2%  14%  343 
Percentage of Schedule III Drugs  3%  14%  174 
Percentage of Brand-Name Drugs  28%  68%  116 
     Total Number of General-Care Physicians  736* 
*A number of prescribers exceeded multiple thresholds.  As a result, the sum of prescribers exceeding the thresholds does not equal 
736. 
Note:  For the purposes of this report, we considered a prescription to be one PDE record. 
Source:  OIG analysis of Part D data, 2012. 
   
 
47 Our review included 86,818 general-care physicians.  To identify general-care 
physicians who were outliers, we first used the Tukey method, described in footnote 42. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  15 
   
 
 
  Examples of Questionable Prescribing Patterns 
 
 
  Medicare paid a total of $9.7 million151 times more than the average 
for on e California physicians prescriptions.  Most of this physicians 
prescriptions were filled by just two independent pharmacies, both of which 
 
OIG identified as having questionable billing.   
 
 
  Seven ty-eight percent of the prescriptions ordered by one Florida physician 
were for Schedule II drugs.  For one beneficiary, this physician prescribed 
 
large quantities of four Schedule II drugs a 605-day supply of morphine 
sulfat e, a 524-day supply of oxycodone HCl, a 460-day supply of fentanyl, 
and a 347-day supply of hydromophone HCl.   
 
 
  Fifty- seven percent of one Tennessee physicians prescriptions were for 
Sched ule II or III drugs.  This physician prescribed an average of 8  
Schedule II prescriptions for each of his 427 beneficiaries, who filled their 
 
prescriptions at 368 different pharmacies. 
   
 
 
One hundred eight general-care physicians prescribed an 
extremely high number of prescriptions per beneficiary 
Although some of this prescribing may be legitimate, ordering a high 
average number of prescriptions per beneficiary could mean that a 
physician is prescribing drugs that are not medically necessary.  
As shown in Table 5, 108 general-care physicians prescribed an extremely 
high number of prescriptions per beneficiary.  These physicians each 
ordered an average of 71 or more prescriptions per beneficiary, which was 
more than 5 times general-care physicians national average of 13.  
Further, 24 of these physicians ordered more than 400 prescriptions for 1 
or more beneficiaries.  In one extreme case, an Ohio physician ordered 
more than 400 drugs each for 13 of his 665 beneficiaries.  In total, this 
physician ordered 50,430 drugs that were dispensed by 100 pharmacies in 
18 States.  This raises questions about whether these prescriptions were 
legitimate.  In another example, a Texas physician ordered more than 
400 prescriptions each for 16 beneficiaries.  He prescribed 700 or more 
drugs for 3 of these beneficiaries in 2009.   
 
 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  16 
   
Thirty-five general-care physicians had prescriptions filled by 
an extremely high number of pharmacies 
This measure raises questions about whether these prescriptions were 
legitimate or necessary.  For example, it may indicate that the physicians 
identification number or prescription pad was stolen or sold and then used 
to write illegal prescriptions and submit false Medicare claims.  
Thirty-five general-care physicians each had prescriptions filled by at least 
342 pharmacies.  This was over six times the national average of 52 per 
general-care physician.  In one case, prescriptions from one general-care 
physician in Illinois were filled by 872 pharmacies located in 47 States 
and Guam.  Medicare paid $783,686 for these drugs.   
In another case, prescriptions from a general-care physician in New Jersey 
were filled by 608 pharmacies located in 41 States and Puerto Rico.  
Medicare paid $380,847 for these drugs.  
Overall, 483 general-care physicians ordered an extremely 
high percentage of Schedule II or Schedule III drugs, which 
have potential for addiction and abuse 
Schedule II and III drugs have a high risk for abuse.  Although some of 
this prescribing may be appropriate, prescribing a high percentage of these 
drugs may indicate that a physician is ordering medically unnecessary 
drugs, which may be used inappropriately or diverted and resold.  Misuse 
of these drugs has serious human and financial costs.  
A total of 483 general-care physicians ordered an extremely high 
percentage of Schedule II or III drugs.  Specifically, 343 general-care 
physicians ordered a high percentage of Schedule II drugs:  at least  
14 percent of the prescriptions ordered by each of these physicians were 
for Schedule II drugs.  This was seven times the national average for 
general-care physicians.  The most common Schedule II drugs ordered by 
these physicians were oxycodone HCl, morphine sulfate, and methadone 
HCl.   
In one example, about 80 percent of the prescriptions ordered by one Ohio 
physician were for Schedule II drugs.  Also troubling is that this physician 
had 106 Part D beneficiaries and 98 of them received oxycodone HCl.  
Another California physician ordered 115 Schedule II drugs for  
1 beneficiary in 2009.  Medicare paid $425,711 for these drugs, which 
were dispensed by 11 pharmacies.  In another case, 68 percent of a 
Wisconsin physicians prescriptions were for Schedule II drugs.  On 
average, he ordered about 14 Schedule II prescriptions for each of his 
300 beneficiaries.   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  17 
   
In addition, 174 general-care physicians ordered a high percentage of 
Schedule III drugs.  Fourteen percent or more of the prescriptions ordered 
by each of these physicians were for Schedule III drugs.  This is five times 
general-care physicians national average.  The most common Schedule III 
drugs prescribed by these physicians were hydrocodone-acetaminophen, 
acetaminophen-codeine, and Suboxone.  Interestingly, for five prescribers 
35 percent or more of the drugs each ordered were Schedule III.  Four of 
these prescribers were located in Kentucky and the fifth was in Tennessee.  
One hundred sixteen general-care physicians prescribed an 
extremely high percentage of brand-name drugs 
While some of this prescribing may have been appropriate, ordering a high 
percentage of brand-name drugs may indicate that a physician has 
inappropriate incentives to order certain drugs because brand-name drugs 
are more expensive than generic. 
A total of 116 general-care physicians prescribed an extremely high 
percentage of brand-name drugs.  At least 68 percent of the prescriptions 
ordered by each of these physicians were for brand-name drugs, compared 
to general-care physicians national average of 28 percent.  In one case, a 
California physician ordered 82 percent of his prescriptions for 
brand-name drugs.  Medicare paid a total of $9.7 million for his 
prescriptions in 2009151 times more than the average amount.  He also 
ordered an unusually large number of prescriptions for Lovaza, which is a 
prescription Omega-3-acid.  
Further, 15 percent of these general-care physicians were 
associated with retail pharmacies with questionable billing 
A total of 110 of the 736 general-care physicians were associated with one 
or more of the retail pharmacies we previously identified as having 
questionable billing. 48   In each case, the retail pharmacy billed for at least 
25 percent of the total cost of the Part D drugs that the physician 
prescribed in 2009.   
Most of the physicians were associated with one retail pharmacy with 
questionable billing; however, five physicians were associated with two 
pharmacies each.  In one case, 90 percent of one physicians prescriptions 
were filled by two pharmacies with questionable billing.  These 
prescriptions amounted to $3.1 million.     
 
48 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600,  
May 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  18 
   
CONCLUSION AND RECOMMENDATIONS 
We found hundreds of general-care physicians nationwide with 
questionable prescribing patterns.  While there may be legitimate reasons 
for some of this prescribing, all of these physicians warrant further 
scrutiny.  We found that many prescribed extremely high proportions of 
Schedule II or III drugs.  These drugs have high risk for abuse and may be 
diverted and sold for profit.  Many other physicians prescribed high 
numbers of drugs per beneficiary or high proportions of brand-name 
drugs, which may indicate that the prescriptions are medically 
unnecessary.  Further still, some prescribers had their prescriptions filled 
at extremely high numbers of pharmacies, again raising concern about the 
legitimacy of the prescriptions. 
These findings show the need for increased oversight of Part D.  OIG is 
committed to continuing its investigations and audits of Part D and to 
following up on prescribers, as appropriate.  CMS must take steps to 
effectively identify and prevent prescriber related fraud, waste, and abuse 
in Part D.   
We recommend that CMS: 
Instruct the MEDIC to Expand Its Analysis of Prescribers 
CMS should work with the MEDIC to ensure that it effectively and 
systematically monitors prescribers to identify those with questionable 
patterns.  As this study shows, prescribing patterns vary significantly by 
specialty; therefore, taking specialty into account is an important step in 
identifying prescribers with questionable patterns.  We recommend that 
the MEDIC expand the analysis in this report and review other specialties 
for questionable prescribing patterns.  The MEDIC should use the 
measures in this report, as well as others it deems appropriate.     
Provide Sponsors With Additional Guidance on Monitoring 
Prescribing Patterns 
CMS should provide additional guidance to sponsors on how to effectively 
monitor prescribing patterns.  CMS should emphasize the importance of 
using data analysis to identify prescribers with questionable patterns.  
Specifically, CMS should recommend that sponsors compare physicians 
with similar specialties when conducting such analysis.   
In addition, CMS recently issued guidance to sponsors on how to improve 
their Drug Utilization Reviews to prevent overutilization of certain Part D 
drugs.  This guidance suggests that sponsors use PDE data to identify and 
follow up on beneficiaries who are receiving extremely high dosages of 
opioids.  CMS should provide further guidance to sponsors suggesting that 
they identify prescribers who are associated with a high number of these 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  19 
   
beneficiaries and refer these prescribers to the MEDIC or law enforcement if 
fraud is suspected. 
Provide Education and Training for Prescribers 
CMS should provide education and training to prescribers.  Although 
CMS does not have a direct contractual relationship with prescribers under 
Part D, it is in the best position to assess and educate prescribers about 
prescribing patterns.  CMS should provide prescribers with reports 
comparing their prescribing patterns to their peers.  Similar to the 
Comparable Billing Reports issued for other services, such as Part B, these 
reports would provide prescribers with important educational information 
and insight about their prescribing patterns.   
CMS should also conduct a communication and educational campaign for 
prescribers about the overutilization of prescription drugs.  Specifically, 
the campaign should raise awareness about prescription drug abuse and to 
remind prescribers that Part D only covers drugs that are used for 
medically indicated purposes.  It should also educate prescribers about 
what constitutes Medicare fraud and the potential consequences of 
committing it.  These efforts will help to ensure that physicians prescribe 
drugs only for lawful purposes. 
Follow Up on Prescribers With Questionable Prescribing 
Patterns 
In a separate memorandum, we will refer the general-care physicians with 
questionable prescribing patterns to CMS for appropriate action. 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  20 
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
 
In its comments on the draft report, CMS concurred with all four of the 
recommendations.  CMS concurred with our first recommendation and 
stated that it will continue to work with the MEDIC to expand its analysis 
of prescribers and build on the analysis of prescribing patterns provided by 
OIG in this report.  Additionally, CMS has increased its monitoring of 
prescribers through the Part D Recovery Audit Contractor with which 
CMS has contracted to identify and recover improper payments in the Part 
D program. 
CMS concurred with our second recommendation and stated that it has a 
responsibility for monitoring prescribing patterns beyond the 
responsibility of sponsors, because it has all prescribing data for Part D 
and sponsors have prescribing data for only their enrollees.  To help 
sponsors overcome limitations in the plan data, CMS will provide general 
guidance red flags to sponsors concerning aberrant and abusive  
prescribing patterns it detects that may not be apparent to individual 
sponsors.  It also stated that, as a part of its opioid overutilization policy, 
CMS has already provided the guidance to Part D sponsors that this 
recommendation suggests on the critical area of opioid prescription drug 
abuse.  In addition, the MEDIC will conduct a presentation on drug 
overutilization at the next quarterly fraud work group meeting. 
CMS concurred with our third recommendation and stated that it has 
already engaged in communication and education for prescribers about the 
overutilization of prescription drugs in the annual Medicare Dear Doctor 
letter (i.e., the Announcement About Medicare Participation for Calendar 
Year 2013).  CMS also stated that it engaged in an additional initiative to 
provide training and education through the Medicare Learning Network.  
CMS concurred with our fourth recommendation and stated that it is 
committed to following up, as necessary, to determine whether the 
individual physician prescribing patterns are indications of likely fraud or 
abuse.  
We support CMSs efforts to address these issues.  For the full text of 
CMSs comments, see Appendix C. 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  21 
   
APPENDIX A 
 
Specialties of Part D Prescribers 
Percentage of All  
Specialty   Percentage of All Part D Prescribers 
Part D Prescriptions 
General Care  19.8%  65.5% 
Dentistry  13.7%  0.6% 
Nurse Practitioners  6.5%  3.4% 
Physician Assistants  4.9%  2.1% 
Emergency Medicine  3.7%  0.9% 
Psychiatry  3.6%  3.0% 
Obstetrics and Gynecology  3.4%  0.5% 
Surgery  2.7%  0.4% 
Cardiology  2.1%  5.2% 
Anesthesiology  1.6%  0.3% 
Ophthalmology  1.6%  1.3% 
Neurology  1.2%  1.1% 
Gastroenterology  1.1%  0.8% 
Hematology and Oncology  1.0%  0.7% 
Dermatology  1.0%  0.4% 
Urology  0.9%  0.8% 
Pulmonary  0.8%  1.0% 
Nephrology  0.7%  1.3% 
Physical Medicine and Rehabilitation  0.7%  0.4% 
Endocrinology  0.5%  1.0% 
Infectious Disease  0.5%  0.4% 
Rheumatology  0.4%  0.8% 
Other  27.8%  8.0% 
Note:  For the purposes of this report, we considered a prescription  to be one Prescription Drug Event record.    
Source:  Office of Inspector General analysis of Part D data, 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  22 
   
APPENDIX B 
 
Part D Prescribing Patterns by Specialty 
Average 
Average  Average  Average 
Average Number  Number of 
Percentage of  Percentage of  Percentage of 
Specialty   of Prescriptions  Pharmacies 
Schedule II  Schedule III  Brand-Name 
per Beneficiary  Associated With 
Drugs  Drugs  Drugs 
Each Prescriber  
General Care  13  52  2.0%  2.7%  28.3% 
Infectious Disease  11  34  1.6%  1.9%  42.5% 
Cardiology  10  85  0.3%  0.5%  29.4% 
Endocrinology  10  82  0.3%  1.4%  51.4% 
Nephrology  10  69  0.9%  1.5%  29.4% 
Psychiatry  10  30  2.5%  1.0%  34.6% 
Rheumatology  9  96  2.3%  4.4%  20.5% 
Pulmonary  8  61  0.9%  1.0%  56.7% 
Neurology  7  56  2.3%  1.9%  36.7% 
Hematology and 
6  51  8.5%  4.0%  34.2% 
Oncology 
Physical Medicine and 
6  41  14.2%  10.6%  23.8% 
Rehabilitation 
Nurse Practitioners  6  23  3.8%  3.5%  29.6% 
Anesthesiology  5  15  10.7%  7.9%  26.4% 
Gastroenterology  4  66  0.7%  0.9%  39.1% 
Obstetrics and 
4  23  2.5%  3.2%  43.5% 
Gynecology 
Ophthalmology  4  72  0.5%  1.3%  59.4% 
Urology  4  74  1.9%  4.3%  41.7% 
Physician Assistants  4  24  5.6%  8.7%  23.5% 
Dermatology  3  60  0.4%  1.4%  19.7% 
Surgery  3  23  10.9%  18.8%  21.7% 
Emergency Medicine  2  32  7.8%  14.8%  15.8% 
Dentistry  2  12  1.4%  14.2%  8.7% 
Note:  For the purposes of this report, we considered a prescription to be one Prescription Drug Event record.  
Source:  Office of Inspector General analysis of Part D data, 2012.  
 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  23 
  APPENDIXC 
Agency Comments 
Centers for Medicare & Medicaid Services 
Administrator 
Washington, DC 2020 t 
MAY  - 6 2013 
DATE : 
TO:  Daniel R. Levinson 
Inspector General 
FROM:  Matilyn ~enner 
Actirrg Administrator 
SUBJECT:  Office oflnspector General (OIG) Draft Report: "Prescribers with Questionable 
Patterns in Medicare Part D" (OEI-02-09-00603) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the above-subject OIG draft report. The purpose ofthis report is to describe 
Medicare Part D prescribing patterns, to describe the extent to which Part D prescribing patterns 
differ by prescribers' specialties, and to identifY general-care physicians with questionable 
Part D prescribing patterns in 2009. 
Prescription drug abuse is a serious and growing problem. CMS is committed to preventing such 
abuse, particularly in the area ofprescriber fraud.  CMS relies on sponsors to help safeguard 
Part D from fraud and abuse. These sponsors are required to have compliance plans in place that 
enable them to detect, prevent, and correct fraud, waste, and abuse. Additionally, CMS 
recommends that the sponsors use data analysis as part oftheir compliance plans. CMS also 
contracts with a Medicare Drug Integrity Contractor (MEDIC) as part ofits continuing effort to 
detect and prevent fraud, waste, and abuse. This contractor's responsibilities include identifYing 
and investigating potential Part D fraud and abuse, referring such cases to OIG, and fulfilling 
requests for information from law enforcement. 
We appreciate OIG's efforts in working with CMS to increase oversight of the Medicare Part D 
program in an effort to safeguard against prescription drug abuse. CMS concurs with all of 
OIG's recommendations to improve oversight ofPart D and to expand the use ofdata analysis in 
these oversight efforts. Our response to each ofthe OIG recommendations follows. 
OIG Recommendation 
The OIG recommends that CMS should instruct the MEDIC to expand its analysis of prescribers. 
24 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)   
 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  25 
   
 
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  26 
   
   
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  27 
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New York regional 
office, and Nancy Harrison and Meridith Seife, Deputy Regional 
Inspectors General.  
Miriam Anderson served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Jenell Clarke and Jason Kwong.  Central 
office staff who provided support include Eddie Baker, Jr., Kevin Farber, 
Meghan Kearns, Christine Moritz, and Debra Roush.  
 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603)  28 
   
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.