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82–571 PDF 2014

S. Hrg. 113–244 

CURBING PRESCRIPTION DRUG ABUSE IN 

MEDICARE 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED THIRTEENTH CONGRESS 

FIRST SESSION 

JUNE 24, 2013 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

THOMAS R. CARPER, Delaware Chairman 

CARL LEVIN, Michigan 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

MARK BEGICH, Alaska 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

RON JOHNSON, Wisconsin 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JEFF CHIESA, New Jersey 

RICHARD J. KESSLER, Staff Director 

JOHN P. KILVINGTON, Deputy Staff Director 

PETER P. TYLER, Senior Professional Staff Member 

WALTER S. OCHINKO, GAO Detailee 

KEITH B. ASHDOWN, Minority Staff Director 

CHRISTOPHER J. BARKLEY, Minority Deputy Staff Director 

JOSH TRENT, Health Policy Advisor, Office of Senator Coburn 

TRINA D. SHIFFMAN, Chief Clerk 

LAURA W. KILBRIDE, Hearing Clerk 
(III) 

C O N T E N T S 

Opening statements: Page 

Senator Carper ................................................................................................. 1 

Senator Coburn ................................................................................................. 3 

Senator Chisea .................................................................................................. 4 

Prepared statements: 

Senator Carper ................................................................................................. 37 

WITNESSES 

MONDAY, JUNE 24, 2013 

Joseph T. Rannazzisi, Deputy Assistant Administrator, Office of Diversion 

Control, Drug Enforcement Administration, U.S. Department of Justice ...... 6 

Jonathan Blum, Acting Principal Deputy Administrator and Director of the 

Center for Medicare, Centers for Medicare and Medicaid Services, U.S. 

Department of Health and Human Services ...................................................... 8 

Gary Cantrell, Deputy Inspector General for Investigations, Office of Inspector General, U.S. Department of Health and Human Services; and Stuart 

Wright, Deputy Inspector General for Evaluation and Inspections, Office 

of Inspector General, U.S. Department of Health and Human Services ......... 10 

Alanna M. Lavelle, Director, Special Investigations, WellPoint, Inc. ................. 12 

ALPHABETICAL LIST OF WITNESSES

Blum, Jonathan: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 56 

Cantrell, Gary: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 72 

Lavelle, Alanna M.: 

Testimony .......................................................................................................... 12 

Prepared statement .......................................................................................... 82 

Rannazzisi, Joseph T.: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 43 

Wright, Stuart: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 72 

APPENDIX 

List referenced by Senator Carper ......................................................................... 41 

Statement of the National Community Pharmacists Association ....................... 97 

Responses to post-hearing questions for the Record: 

Mr. Rannazzisi .................................................................................................. 100 

Mr. Blum ........................................................................................................... 103 

Mr. Cantrell and Mr. Wright ........................................................................... 117 

Ms. Lavelle ........................................................................................................ 123 

(1) 

CURBING PRESCRIPTION DRUG ABUSE IN 

MEDICARE 

MONDAY, JUNE 24, 2013 

U.S. SENATE, COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 3:08 p.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Thomas R. Carper, 

Chairman of the Committee, presiding. 

Present: Senators Carper, Coburn, and Chiesa. 

OPENING STATEMENT OF CHAIRMAN CARPER 

Chairman CARPER. Well, a room as quiet as this one probably 

does not need me to call everyone to order, but this hearing will 

come to order, and I want to welcome our witnesses. I apologize for 

running a few minutes late, but thank you for being here and for 

your preparation and attendance today for an important hearing. 

Our colleagues are coming in from across the country this afternoon, and we will be joined by a number of them as this hearing 

proceeds. 

Today we are going to hear from several witnesses about the 

Medicare Prescription Drug Program and its vulnerability to waste, 

to fraud, and to abuse. 

Medicare, as we all know, is a critical component of health care 

in our Nation, and the Prescription Drug Program, which we know 

as Part D, began about 7 years ago, in 2006. We are now in its seventh year. The overall reviews of the program have been generally 

positive, more than 31 million seniors participating. The lion’s 

share of them like the program. However, Congress must ensure 

that the $60 billion a year program works effectively and efficiently. Unfortunately, Medicare, including Part D, is not as effective or efficient as it could or should be when it comes to preventing waste and fraud. 

Each year, the Federal Government lists the estimates of overpayments, underpayments, undocumented expenditures, and other 

kinds of mistakes made by each agency. The total for fiscal year 

(FY) 2012 was more than $100 billion. Medicare has the largest reported share of that total at $44.3 billion, and the amount wasted 

in Medicare’s Prescription Drug Program alone is approaching $1.6 

billion. 

In addition, health care is too often the focus of criminals who 

wish to take advantage of the system. Whether the care is provided 

through government programs or the private sector, attempts to 
2 

defraud the health care system are on the rise. There are estimates 

for Medicare fraud in the tens of billions of dollars. 

We cannot afford to tolerate these levels of waste and fraud in 

our health care programs. As everyone in this room knows, we 

have faced record budget deficits in recent years, and while they 

are coming down, they are still way too large. Given the debt and 

deficit problems that our country faces and the tough work ahead 

of us as we attempt to address those challenges, we need to focus 

like a laser on the avoidable, expensive, and, frankly, unacceptable 

issues we will be discussing here today. 

During a Subcommittee hearing that I chaired in the fall of 

2011—and I might be mistaken, but I think Dr. Coburn was there 

as well. I am not positive. I think you were, because of your great 

interest. But the Government Accountability Office (GAO) that day 

testified that they identified about 170,000 beneficiaries who acquired the same class of frequently abused drugs, primarily 

hydrocodone and oxycodone, from five or more medical practitioners at a taxpayer cost of almost $150 million. In two egregious 

examples, individuals received prescriptions from 87 and 58 different medical practitioners. This followed a similar study by the 

GAO in 2009 showing the same problem in Medicaid. 

This fraud technique, called ‘‘doctor shopping,’’ involves recipients going to multiple doctors for the same type of drug. In these 

cases, beneficiaries are almost always either feeding an addiction 

or selling the drugs they do not use on the street. Drug dealers 

make the profits while the Federal Government foots the bill. 

But the problem of prescription drug fraud is about more than 

just a loss of taxpayer dollars. It is also about the toll that drug 

abuse takes on people. It is of great concern that one out of seven 

high school seniors in America has abused, or is abusing, prescription drugs. In fact, more Americans abuse prescription drugs than 

the number who abuse cocaine, heroin, hallucinogens, Ecstasy, and 

inhalants combined. 

The Department of—do we have a chart here anywhere? 

The Department of Health and Human Services (HHS), specifically the Centers for Medicare & Medicaid Services (CMS), has established a set of oversight procedures to protect the Medicare Prescription Drug Program and its beneficiaries from fraud and waste. 

This is a team effort involving Medicare officials, law enforcement 

at the Federal, the State, and the local level, the Medicare prescription drug plans (PDPs), pharmacies and doctors, and the beneficiaries themselves. Unfortunately, based on today’s testimony by 

the Health and Human Services Office of Inspector General (HHS 

OIG), there is still a lot more work to do. 

On Thursday of last week, the Inspector General (IG) released a 

report detailing over 700 general care practitioners who had questionable Medicare Part D prescribing patterns. For example, while 

prescription drugs with a high abuse potential constitute on average only 2 percent of most general practitioners’ prescriptions, they 

constituted 78 percent for one general practitioner identified in the 

report. 

This physician prescribed a year’s supply of three painkillers, 

such as morphine and codeine, for just one Medicare beneficiary. 
3 

1List referenced by Senator Carper appears in the Appendix on page 41. 

Another general practitioner’s prescriptions were filled at 872 pharmacies in 47 States, including Guam. 

Today we will learn about an even more clear failure of oversight. The Inspector General is reporting that Medicare is paying 

for prescription drugs prescribed not by physicians or others authorized to prescribe those drugs, but by people with no authority 

to prescribe at all. Apparently, 400,000 prescriptions totaling some 

$31.6 million were prescribed by individuals who appear to be massage therapists, interpreters, music and art therapists, and contractors who perform health care-related home repairs. And you see 

the list1 there to my left. 

The most disturbing finding in the Inspector General’s report is 

that 29,000 of the prescriptions were for controlled substances, including drugs with a high potential for abuse, such as oxycodone. 

One contractor alone wrote 79 prescriptions for commonly abused 

painkillers. 

Obviously, these numbers and examples show clear indication of 

abuse and fraud. As a recovering Governor, I understand the 

unique challenges that come along with running a major program 

like Medicare. However, we simply have to do a better job in overseeing the Medicare Prescription Drug Program. 

I will continue to work with Dr. Coburn and with our colleagues 

and the Administration to ensure that programs across the Federal 

Government are improving management functions, monitoring results, and finding ways to do more with less in almost everything 

that we do. A key part of these efforts will involve program managers sharpening their pencils and, in conjunction with our private 

sector partners, preventing expensive and harmful waste and 

fraud. We must use every tool available to make sure that our 

health care programs help those who need medications rather than 

feed drug addictions or fraudulent profiteering. By working together on this latest in a series of commonsense initiatives, we can 

take another important step forward in earning their trust once 

again. 

And with that, let me turn to our Ranking Member, Dr. Coburn, 

for any comments he might like to make. Dr. Coburn, welcome. 

OPENING STATEMENT OF SENATOR COBURN 

Senator COBURN. Thank you, Senator Carper. Welcome to each 

of you. 

This IG report is pretty revealing, and I am sitting here thinking 

about what we will be doing next year on the basis of the recommendations not being followed in the IG report, because that 

seems to be the case most often with CMS. And so my question is 

not is it happening. It is: What is wrong with the recommendations 

that the IG is making in this? It fits with common sense. And if 

we come back a year from now, Chairman Carper, and this stuff 

has not been done and the contractor is not either fired or made 

to do what they are supposed to do, what we ought to do is see 

about cleaning house everywhere at CMS. This is just another 

layer in a continuing saga of not applying common sense and OIG 

recommendations to fix problems. 
4 

And so I look forward to hearing the testimony. The problem is 

real. It is not just a problem of wasted dollars. It is wasted lives 

that Medicare is allowing through CMS, and the fact that people 

have identification in Medicare and we have a contractor that is 

not catching the fraud, not revealing the fraud, not prosecuting the 

fraud just says that we are wasting that contract money based on 

what we have seen in the IG report versus what the contractor has 

done. 

So my hope is that we are not back here in a year, that we can 

say, ‘‘Way to go, CMS, you actually followed what the IG did, recommended,’’ and they actually put it into action and we will not 

see this happening again. 

Chairman CARPER. We have a new member on board. This is the 

first hearing he has joined us. He comes from the State of New Jersey. He is my neighbor across the Delaware River. Jeff, we are honored to have you join us here in the U.S. Senate and delighted that 

you have ended up on our Committee. Normally only the Chair and 

Ranking Member give an opening statement, but since this is a 

special day for you. And you come to it I think as the Attorney 

General of your State, if I am not mistaken. Is that correct? 

Senator CHIESA. Yes, it is. 

Chairman CARPER. If you would like to make just a brief statement, please feel free. We are happy to see you and happy to have 

you on our team. 

OPENING STATEMENT OF SENATOR CHIESA 

Senator CHIESA. Well, thank you so much for that warm welcome, Mr. Chairman. I would just say that we took a lot of steps 

in New Jersey because we recognize how catastrophic the prescription drug issue is. 

I think the Chairman talked about the fact that we think about 

heroin and we think about cocaine as things that kill people, and 

we are realizing now that prescription drug abuse is killing more 

people than those drugs are. So while we live in a State that tells 

us that these drugs are safe, they are only safe if we use them exactly as we are supposed to and if the people that are giving us 

the drugs are doing it for the right reasons. 

So I also look forward to this conversation today, a continuing 

conversation that is incredibly important to the safety of everybody 

who lives here. 

Thank you, Mr. Chairman. 

Chairman CARPER. Thank you very much. And, again, a warm 

welcome. 

Our first witness is a witness whose name is probably frequently 

butchered, and I am going to try not to do it today, but is it 

‘‘Rannazzisi’’? 

Mr. RANNAZZISI. That would be perfect. 

Chairman CARPER. OK. I am not often perfect. Joseph T. 

Rannazzisi, Drug—— 

Senator COBURN. I second that. 

Chairman CARPER. Pardon? 

Senator COBURN. I second that. 

Chairman CARPER. Dr. Coburn said he can second that. He sure 

can. [Laughter.] 
5 

Drug Enforcement Administration (DEA), Deputy Assistant Administrator of the Office of Diversion Control at the Drug Enforcement Administration. As the Deputy Assistant Administrator, he is 

responsible for overseeing and coordinating major diversion investigations, drafting and promulgating regulations, and working with 

the pharmaceutical industry, international governments, State governments and other Federal agencies, and with local law enforcement. He holds a B.S. degree in pharmacy from Butler University 

and a J.D. from the Detroit College of Law at Michigan State University. We are delighted to see you today. Thanks for joining us. 

Jonathan Blum very nice to see you—Acting Principal Deputy 

Administrator and Director of the Center for Medicare at the Centers for Medicare & Medicaid Services. He is responsible for overseeing the regulations and payment of Medicare providers and 

plans, including the private plans that participate in the Medicare 

Prescription Drug Program. During the development of the Medicare prescription drug benefit, Mr. Blum was an adviser to the 

Senate Finance Committee working on prescription drugs and 

other Medicare policies. He was also a Medicare program analyst 

at the Office of Management and Budget (OMB). He has testified 

before this Committee before, as well as the Finance Committee before, and we welcome your appearance and testimony today. 

I think I have to introduce the two OIG witnesses together, and 

I believe you are going to be splitting your testimony time. One is 

Gary Cantrell, Mr. Cantrell, nice to see you, and the other is Stuart Wright. We welcome both of you. They are from the Health and 

Human Services Office of Inspector General, where Mr. Cantrell 

serves as the Deputy Inspector General for Investigations. Mr. 

Cantrell has served in various leadership positions within the Office of Investigations where he advanced the office’s use of data 

analysis in health care fraud detections. Mr. Cantrell has B.A.s in 

criminal justice from Georgia State and in computer and information science from the University of Maryland (UMD). 

Mr. Wright is the Deputy Inspector General for Evaluations and 

Inspections. Mr. Wright joined the Office of Inspector General in 

1987 and has held a variety of positions, including Chief of Medicare and Medicaid Branch and Director of the Program Evaluation 

Division, and is a graduate of the University of Rochester where he 

earned a B.S. in economics and political science and a master’s in 

public policy. Thank you both for joining us today. 

Finally, Alanna Lavelle from WellPoint is the last witness, Director of Special Investigations for WellPoint, a large health care company that also participates in the Medicare Prescription Drug Program. She joined WellPoint in 2004 after 24 months of service with 

the Federal Bureau of Investigations (FBI)—no, I am just kidding. 

[Laughter.] 

Twenty five years of service with the FBI, including experience 

fighting health care fraud and bioterrorism. In addition to her duties at WellPoint, she also serves as the Chair of the National 

Health Care Anti-Fraud Association, which brings together the private and public sectors. Her resume suggests that she is eminently 

well qualified to testify, and we are grateful to you for being here 

today. 
6 

1The prepared statement of Mr. Rannazzisi appears in the Appendix on page 43. 

With that having been said, others of our panel are going to join 

us here throughout the afternoon. We start voting at 5:30. I expect 

we will be done by then. We appreciate your being here. 

I am going to ask you to take about 5 minutes to summarize your 

testimony. If you want to go a little beyond that, that is OK. If you 

go way beyond that, it is not. So please proceed, Mr. Rannazzisi. 

TESTIMONY OF JOSEPH T. RANNAZZISI,1 DEPUTY ASSISTANT 

ADMINISTRATOR, OFFICE OF DIVERSION CONTROL, DRUG 

ENFORCEMENT ADMINISTRATION, U.S. DEPARTMENT OF 

JUSTICE 

Mr. RANNAZZISI. Good afternoon, Chairman Carper, Ranking 

Member Coburn, Senator Chiesa. On behalf of Administrator 

Michele Leonhart and the men and women of the Drug Enforcement Administration, thank you for the opportunity to appear 

today to discuss the epidemic of pharmaceutical controlled substance abuse and the diversion of pharmaceutical controlled substances. 

The abuse of prescription drugs continues to plague the Nation 

at an alarming rate, crossing all age, gender, race, and socioeconomic boundaries. Studies show substantially high levels in the 

abuse of these drugs and the adverse consequences resulting from 

abuse. According to the most recent National Survey on Drug Use 

and Health (NSDUH), in 2011 there were approximately 6.1 million people over the age of 12 who used prescription-type psychotherapeutic drugs for non-medical reasons during the past month. 

The devastating effects of this statistic can be demonstrated by a 

report released in 2013 by the Drug Abuse Warning Network, 

which revealed a 153-percent increase in emergency room (ER) visits from 2004 to 2011 attributable to narcotic pain relievers. 

Oxycodone and hydrocodone were the two opiates most frequently 

implicated in these ER visits. 

As these substances are increasingly diverted and abused, the 

number of pharmaceutical overdose deaths has correspondingly increased. A Centers for Disease Control (CDC) analysis revealed 

38,329 people died from a drug overdose in the United States in 

2010. Nearly 60 percent of the drug overdose deaths involved pharmaceuticals. Again, opioid analgesics, oxycodone, hydrocodone, and 

methadone were involved in about three of every four pharmaceutical overdose deaths. Oxycodone and hydrocodone, by the way, 

are the top two diverted drugs in the United States. 

The diversion and abuse of pharmaceutical controlled substances 

is a problem that cannot be addressed through law enforcement action alone. A multidisciplinary approach is necessary to address the 

threat. The Office of National Drug Control Policy’s 2011 Prescription Drug Abuse Prevention Plan has outlined a multipronged approach that includes education, prescription monitoring, disposal, 

and enforcement to comprehensively address the national epidemic. 

DEA plays an important role in education, disposal, and enforcement. 

DEA participates in and hosts numerous education programs for 

registrants, health care providers, and community groups. In 2011, 
7 

we began a program to educate health care professionals on the 

front lines of diversion, pharmacies and pharmacy techs, on diversion trends and their role in preventing diversion. These Pharmacy 

Diversion Awareness Conferences (PDACs), have been held in nine 

States thus far, providing continuing education to nearly 4,000 

pharmacists and techs. We just finished a controlled substance 

manufacturer, importer, and exporter conference last week, training almost 400 corporate representatives. We also continue to 

present at State and local community meetings and law enforcement programs throughout the country. 

The accumulation of unwanted and unused prescription drugs in 

the household medicine cabinet continues to provide easy access to 

non-medical users for abuse, accidental ingestion, and illegal distribution. This easy access to drug seekers, especially teenagers, 

has undoubtedly contributed to the increase in the abuse of these 

substances. DEA has responded by coordinating national take-back 

events with our law enforcement partners since September 2010. 

These events have resulted in the destruction of approximately 2.8 

million pounds of unwanted prescription drugs. DEA is finalizing 

regulations implementing the Secure and Responsible Drug Disposal Act of 2010, which authorizes additional ways for Americans 

to dispose of their unwanted and expired controlled substance 

medications in a secure and responsible manner. 

The diversion of controlled substances occurs at all levels of the 

supply chain, and we continue to identify, target, and investigate 

violators who cause millions of dosage units of controlled substances to be diverted due to noncompliance with the Controlled 

Substances Act (CSA) and its implementing regulations. Noncompliance is allowing dangerous pharmaceuticals to pour into the 

illicit market, posing an imminent danger to public health and 

safety. 

Pharmaceutical diversion can be prevented if DEA registrants 

fulfill their obligations under the Controlled Substances Act. When 

the system breaks down, massive diversion occurs, as seen in domestic Internet drug distribution schemes a few years ago and the 

rogue pain clinics operating in Florida, Georgia, and Tennessee 

today. DEA rigorously pursues criminal, administrative, and civil 

actions against registrants who fail to comply with the CSA and 

their implementing regulations. 

On June 11, 2013, Walgreens Corporation, the Nation’s largest 

drug store chain, agreed to pay the largest civil fine in DEA history, about $80 million, resolving DEA’s administrative actions and 

a civil investigation by DEA and the United States Attorney regarding the Jupiter, Florida, Distribution Center and six retail 

pharmacies in Florida. This is only the latest in a series of enforcement and regulatory operations focused on all levels of the registrant population within the drug delivery system. They were not 

complying with the CSA. All levels of the distribution chain, from 

manufacturing, wholesalers, retailers, pharmacies, and practitioners, are being closely scrutinized to ensure compliance with the 

act. 

Controlled substance pharmaceuticals that are illegally obtained 

through health care fraud or abuse of the Medicaid program is yet 

another method of diversion that ultimately weakens the integrity 
8 

1The prepared statement of Mr. Blum appears in the Appendix on page 56 

of the closed system of distribution. While these violations generally occur outside of DEA’s jurisdiction, there are occasions when, 

while investigating violations of the Controlled Substances Act, 

DEA agents and investigators uncover violations involving health 

care fraud. This information is shared with investigators from the 

Department of Health and Human Services, the Federal Bureau of 

Investigation, and other State and local enforcement and regulatory bodies with relevant Federal and State authorities. 

The importance of these cooperative and information-sharing relationships is reflected in the fact that HHS OIG and the FBI and 

others have investigated assigned or are working on an ad hoc 

basis with some of the Tactical Diversion Squads (TDSs) throughout the country. This collaborative effort facilitates information 

sharing between all the involved agencies and allows investigators 

to easily draw upon each other’s expertise when conducting investigations and avoiding duplication of effort. 

In conclusion, I want to assure you that DEA is working closely 

with our Federal, State, and local partners in combating drug diversion and, when encountered, health care fraud as part of the administration’s comprehensive approach to combating prescription 

drug abuse. DEA is committed to balancing the need for diversion 

control and the enforcement with the need for access to these important medications by legitimate users. 

Thank you for the opportunity to appear today, and I look forward to your questions. 

Chairman CARPER. Thanks very much for that testimony. 

Mr. Blum, you are recognized. Welcome. 

TESTIMONY OF JONATHAN BLUM,1 ACTING PRINCIPAL DEPUTY ADMINISTRATOR AND DIRECTOR OF THE CENTER FOR 

MEDICARE, CENTERS FOR MEDICARE & MEDICAID SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Mr. BLUM. Chairman Carper, Ranking Member Coburn, Senator 

Chiesa, thank you for inviting CMS to testify at this hearing and 

for your focus on the Part D program. I want to assure this Committee that CMS takes very seriously the concerns being raised 

today. Not only does inappropriate prescribing weaken the fiscal integrity of the Part D program, but it places our beneficiaries in 

harm’s way. 

CMS sincerely thanks the OIG for its work, and we welcome further oversight to help us improve the Part D program. We have 

taken many steps to reduce waste, fraud, and abuse in the Part D 

program, but clearly we can and should do more to take further 

steps. 

To be sure, the Medicare Part D program is stronger than ever. 

It has dramatically lowered Medicare beneficiaries’ out-of-pocket 

costs since 2006. Due to strong management by CMS and our plan 

partners, its total costs are lower than what the Congressional 

Budget Office (CBO) and our actuaries projected when the benefit 

was passed in 2003. In many respects, Part D sets the standard for 

all payers for cost containment measures. However, its statutory 

construct of operating the program through hundreds of Part D 
9 

plan sponsors presents vulnerabilities, and like all payers, public 

and private, Part D has seen rapid growth in payments for Schedule II pain medications. 

We know that no one agency can solve these challenges, and that 

it will take resources from all levels of the government, Federal 

and State, and the private sector to solve this problem. 

CMS sees its role as the following: 

No. 1, to leverage CMS’ data resources of complete Part D claims 

to spot outlier prescribing and share this information with our 

partners in as real time as possible. 

No. 2, to hold sponsors, prescribers, pharmacies, and our contractors accountable for prescribing that is consistent with our goals 

and values. Those that violate our standards should expect to no 

longer have a relationship with the Medicare program. 

No. 3, to support this Committee and the Congress in crafting 

further legislation to give the Federal Government more tools to 

address prescribing fraud. 

Over the past several years, CMS has made some important 

changes to our policies and operations not reflective in 2009 claims 

files. Specifically, CMS has changed our rules to require all Part 

D drug claims to have a valid national provider number attached 

to it. Already in the first quarter of 2013, 99.6 percent of all Part 

D claims were compliant with this requirement. CMS now requires 

all claims for controlled substances to be checked for a valid DEA 

number. 

CMS now requires all Part D plans to conduct more comprehensive drug utilization reviews for beneficiaries taking controlled substances. Part D plans must now verify that beneficiaries who exceed certain levels of prescribing are, one, being managed by a physician or, two, cutoff at the point of sale. To date, this program has 

cutoff 37 beneficiaries. We expect this number to grow, and we also 

expect to expand this program to other medications. 

We have now begun to leverage the fraud prevention system 

(FPS) to identify outlier prescribers and pharmacies much earlier 

in the process. For example, last week, CMS provided to all Part 

D plans a comprehensive list of high-risk pharmacies for further 

review and scrutiny. 

While we feel these actions will help curb Part D fraud, we also 

plan to take more action. For example, CMS is now considering 

proposing new regulations that would require all Part D prescribers be validated as Medicare providers. 

CMS is considering new regulations that would expand the scope 

of our Part D fraud contract, the Medicare Drug Integrity Contractor (MEDIC), to provide greater access to Pharmacy Benefit 

Management (PBMs’), pharmacies’, and prescribers’ records at the 

physical premises. CMS will expand its Part D plan compliance reviews. Part D plans that submit claims for controlled substances 

greater than norms should expect further compliance actions and 

potential financial penalties. 

In closing, I do believe further legislation may be needed to curb 

controlled substance abuse. Some plan sponsors have recommended 

locking in some patients to one pharmacy to receive controlled substances. We believe it is time for Congress to consider this potential 
10 

1The prepared statement of Mr. Cantrell and Mr. Wright appears in the Appendix on page 

72. 

change. CMS stands ready to help this Committee to continue to 

make the Part D program as strong as possible. 

Chairman CARPER. We are interested in exploring that and other 

ideas that require our action, because this is a shared responsibility, and it is an all-hands-on-deck initiative. 

Mr. Cantrell, please proceed. Mr. Wright, you guys figure this 

out. 

TESTIMONY OF GARY CANTRELL,1 DEPUTY INSPECTOR GENERAL FOR INVESTIGATIONS; AND STUART WRIGHT, DEPUTY 

INSPECTOR GENERAL FOR EVALUATION AND INSPECTIONS, 

OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF 

HEALTH AND HUMAN SERVICES 

Mr. CANTRELL. Good afternoon, Chairman Carper, Ranking 

Member Coburn, and Senator Chiesa. We appreciate the opportunity to speak to you today about prescription drug diversion in 

the Medicare program. 

In addition to the Medicare dollars stolen, there are few areas of 

health care fraud where we see such a direct and devastating impact to patients. The CDC has characterized prescription drug 

abuse as an epidemic, and too much of the time the bill is being 

paid by Medicare. This is a drug trade subsidized by the taxpayers. 

Bringing these criminals to justice is a top priority for OIG, and 

over the last 5 years, our prescription drug fraud investigations 

have nearly quadrupled. 

Of particular concern are those prescription drug schemes that 

result in patient deaths. These are often associated with sham pain 

clinics or pill mills. One particular clinic was associated with the 

deaths of over 60 patients. The doctor and his wife, who was a 

nurse and the office manager, were sentenced to over 30 years in 

prison and ordered to pay back $114 million for their crimes. 

Prescription drug fraud also often involves sophisticated criminal 

enterprises. One case involved a licensed pharmacist who owned 26 

pharmacies. He was the mastermind of a scheme that enlisted physicians, pharmacists, and patient recruiters to defraud Medicare, 

Medicaid, and private health insurance. He paid kickbacks and 

other inducements to physicians to write bad prescriptions. The 

pharmacist responsible for this egregious scheme was sentenced to 

17 years in prison and ordered to pay back $17 million. 

Prescription drug schemes are not limited to controlled substances. OIG also investigates matters that involve expensive noncontrolled substances. In one example, a pharmacy billed for medically unnecessary and very expensive antipsychotic, respiratory, 

and cardiac drugs but never dispensed the drugs. The perpetrators 

of this scheme were sentenced to nearly 5 years in prison and ordered to pay $4.9 million. 

These cases illustrate what happens when greed and profit 

trump patient care. And now my colleague Stuart Wright will discuss how better oversight will help curb these problems. 

Mr. WRIGHT. Good afternoon. I am Stuart Wright, Deputy Inspector General for Evaluation and Inspections in the Office of In-
11 

spector General. I appreciate the opportunity to talk about our 

most recent work examining Medicare prescription drug billing as 

well as our body of work related to Part D. Our written statement 

outlines this work in more detail. 

A basic safeguard in paying for medical care is ensuring that the 

care is ordered by an appropriate medical professional. A report 

that we released today shows that this safeguard is not always operating effectively. Nationwide, Medicare Part D paid more than $5 

million in 2009 for prescriptions ordered by individuals who clearly 

did not have the authority to prescribe. These individuals included 

massage therapists, athletic trainers, dental hygienists, and contractors responsible for home repairs. We even found that interpreters, lodging companies, and veterinarians ordered prescriptions. 

In addition, we reviewed 10 States in depth and found that Medicare inappropriately paid for drugs ordered by other types of unauthorized prescribers, such as counselors, social workers, and chiropractors. Medicare paid more than $26 million for these drugs. 

Senator Carper, as you indicated in your opening remarks, tens of 

thousands of these prescriptions were for controlled substances. 

Vulnerabilities in Part D are not limited to unauthorized prescribers. In our report issued last week, we identified questionable 

prescribing patterns by 736 general care physicians. In total, Medicare paid $352 million for drugs ordered by these physicians in 

2009. These physicians were extreme outliers and prescribed very 

differently than their peers. Some ordered extremely high percentages of certain controlled substances, such as oxycodone and morphine. In one example, Medicare paid $9.7 million for one California physician’s prescriptions. This is 151 times more than the 

average prescriber. We also found 24 doctors who ordered more 

than 400 prescriptions for at least one of their patients. 

In another review, we found approximately 2,600 retail pharmacies that billed far outside the norm. Medicare paid a total of 

$5.6 billion in 2009 to these pharmacies. 

While some of these billings may be appropriate or may be due 

to billing errors, these patterns raise flags that warrant further review. This demonstrates that basic checks need to be done routinely by Medicare administrators and contractors. 

In addition to conducting claims analysis, since the inception of 

Part D, we have examined CMS’s oversight program and identified 

vulnerabilities. Notably, we found that some plan sponsors did not 

identify any fraud and abuse cases, and the MEDIC has not fully 

utilized data analytics to identify potential fraud and abuse. 

Taken together, our findings consistently demonstrate the need 

to strengthen Part D monitoring and oversight. Our written statement highlights a number of recommendations, including: Require 

sponsors to verify that prescribers have the authority to prescribe 

drugs; strengthen the MEDIC’s and sponsors’ monitoring of prescribers and pharmacies; require sponsors to refer potential fraud 

and abuse incidents to CMS; develop a mechanism to recover payments for inappropriate Part D claims; and provide education and 

training for prescribers, including issuing reports to prescribers 

with information about their prescribing patterns. 
12 

1The prepared statement of Ms. Lavelle appears in the Appendix on page 82. 

In conclusion, more needs to be done to ensure patient safety and 

to prevent fraud, waste, and abuse. CMS, the MEDIC, and plan 

sponsors need to conduct rigorous oversight and monitoring. The 

OIG will continue to bring all of the oversight and enforcement 

tools at our disposal to protect Part D and its beneficiaries. 

Thank you for your interest in this important issue and for the 

opportunity to present the results of our most recent work. We 

would be happy to answer any questions. 

Chairman CARPER. Thanks, Mr. Wright, and we will have some, 

believe me. 

Ms. Lavelle, welcome. Please proceed. 

TESTIMONY OF ALANNA M. LAVELLE,1 DIRECTOR, SPECIAL 

INVESTIGATIONS, WELLPOINT, INC. 

Ms. LAVELLE. Thank you. Chairman Carper, Ranking Member 

Coburn, and Senator Chiesa, I am Alanna Lavelle, Director of Special Investigations for WellPoint. I also serve as the Chair of the 

National Health Care Anti-Fraud Association. Thank you for the 

opportunity to provide input and recommendations on prescription 

drug abuse in the health care delivery system. 

One of the significant strengths that we and other health plans 

bring to the fight against prescription drug abuse is the data available from our integrated health care delivery systems. This allows 

the ability to see the entire health care spectrum and to spot 

trends and outliers, such as an overprescribing physician or a patient receiving several prescriptions from several providers or pharmacies. 

To combat fraud and abuse, WellPoint has a dedicated fraud and 

abuse prevention team known as the Special Investigations Unit 

(SIU). I am one of their lead investigators, overseeing a team in the 

Southeast region. The SIU is staffed with former Federal and State 

law enforcement agents and medical professionals. We also have a 

data analysis team. 

Today some of the top fraud and abuse schemes we currently see 

in prescription drug coverage include: 

The practice often referred to as ‘‘doctor shopping,’’ whereby individuals obtain prescriptions for frequently abused drugs from multiple prescribers and then fill them at different pharmacies. Oftentimes providers as well as pharmacies are involved in the scheme; 

Bogus providers: these are the providers that, although they may 

have National Provider Identifier numbers (which are usually stolen or purchased), do not actually perform services for real patients 

but bill insurers; 

And pain management doctors overprescribing pain medications. 

WellPoint currently has 160 investigations open involving Medicare Part D. WellPoint refers every Part D case to the MEDIC, 

Medicare’s Part C and D anti-fraud contractor, and WellPoint currently has the second highest number of referrals to the MEDIC 

nationwide. 

Our goal at WellPoint is to prevent health care fraud and abuse 

for the benefit of our members’ health. To meet this goal, we have 

developed a number of different programs. 
13 

First we have our Controlled Substance Utilization Monitoring 

(CSUM) Program and Medicaid Restricted Recipient Program. 

Through these programs, we are helping identify those who are engaged in or contributing to prescription drug abuse or drug diversion. 

For our Medicaid plans, we have implemented a Restricted Recipient Program. Through this program we identify a member who, 

within a 3-month period, visited three or more prescribing providers, three or more pharmacies, and filled ten or more controlled 

substance prescriptions without a confirmed underlying medically 

necessary condition. 

To combat fraud and abuse of Schedule II narcotics, such as 

OxyContin, they are locked into using only one primary care physician, one retail pharmacy of their choice, and one hospital. Our 

case managers work directly with providers and members, and to 

date, this program has saved lives and many millions of dollars in 

emergency department visits alone for the drug-seeking behavior. 

Second, we have a Prepayment Review Program to identify irregular provider practice patterns through data mining and analytics. 

WellPoint has implemented two such prepaid provider review programs in which the most egregious billers who, after being educated and refusing to modify their billing behavior, are placed on 

flagged prepayment review. In that case, providers must bill us 

with paper claims accompanied by paper medical records so that 

we can determine whether the procedures billed for are reflected in 

the records. 

And, third, we have recently contracted with a vendor to do predictive modeling. This program uses advanced neural network technology from FICO to identify previously unknown and emerging 

fraud and abuse provider or member schemes. Suspect providers 

and claims are reviewed to identify potential fraud, waste, or abuse 

and investigated thoroughly. Since we began using this tool 6 

months ago, the SIU has opened 200 investigations. 

We will prevent this year, in 2013, over $13 million in inappropriate payments by having placed a system edit for urine drug testing abuse by providers, which is one of the largest collateral abuses 

spawned by the prescription drug abuse in the United States. The 

overall return on investment at this time is well over 15:1. 

And, finally, we take a multifaceted approach to identifying 

bogus providers who do not actually perform services for real patients. Our provider database teams alerts the investigator to the 

presence of new labs, pharmacies, and durable medical equipment 

(DME) suppliers, and we perform a full background check as well 

as a drive-by of the provider’s office space. 

In just the last 6 months, we have identified and stopped payment to 63 bogus pharmacies through our collaboration with our 

PBM Express Scripts, resulting in a savings of $2.1 million. 

Based on our experience in combating health care fraud and 

abuse, we offer the following recommendations: 

First, we are supportive of giving CMS the authority to establish 

a Restricted Recipient Program in Medicare Part D for those beneficiaries displaying a pattern of misutilization. 

Second, we recommend—— 
14 

Chairman CARPER. Is that another way of saying the lock-in program? 

Ms. LAVELLE. Yes, that is correct. 

Chairman CARPER. OK. 

Ms. LAVELLE. Second, we recommend that dually eligible beneficiaries with evidence of drug-seeking behavior should be locked 

into one managed care plan rather than continue to be allowed to 

switch plans on a monthly basis to evade detection. 

Third, we support better coordination and cooperation among 

CMS, the Department of Justice (DOJ), and all stakeholders. 

And, finally, all expenses for health insurer anti-fraud and abuse 

programs should be included as ‘‘activities that improve health care 

quality’’ in the medical loss ratio (MLR) calculation for both commercial health insurers as well as Medicare Advantage since they 

reduce waste, reduce the cost of health care, and enhance patient 

safety by helping identify and remove providers engaging in unsafe 

and fraudulent practices. 

In conclusion, I would like to thank the Committee for the opportunity to testify today on behalf of WellPoint on this critical issue 

and pledge our support in any efforts to make the health care system financially viable and safer for our members. 

Chairman CARPER. Thanks. Ms. Lavelle. 

Just to put this in some context, Dr. Coburn and I focus on—and 

I will just say to our new colleague, whose name I believe is pronounced ‘‘Key-ay-sa,’’ not—— 

Senator CHIESA. ‘‘Chee-ay-sa.’’ 

Chairman CARPER. Has it ever been mispronounced? 

Senator CHIESA. Has it ever been? Never. [Laughter.] 

Chairman CARPER. All right. Well, I will work on that. 

To put this in context, our budget deficit is down. We are down 

from about $1.4 trillion maybe 4 years ago. We are told this year 

it is only going to be about $650 billion. It was $1.4 trillion about 

4 years ago. That is an improvement. The biggest piece of our deficit—and we are going to actually get closer to a balanced budget— 

is health care costs, and the 800-pound gorilla in the room is probably Medicare. And rather than cutting benefits that people actually need that are doing a lot of good, what we have to do is to look 

for every bit of money that is just wasted, spent inefficiently, fraudulently, and that brings us to today’s hearing. 

We have some numbers up here on this board. These are 2009 

numbers. It is money that Medicare paid apparently inappropriately for prescription drugs that year. About 417,000 prescriptions 

that year, some 29,000 controlled substance prescriptions, involving 

maybe 15,000 or so prescribers, cost a loss to taxpayers of $31.6 

million. My fear is that this understates the situation. 

We never conduct ‘‘gotcha’’ hearings here. We never do that, and 

we are not going to do that today. I just want to impart a sense 

of urgency. We do not have the money to be wasting, whether it 

is $31 million, $131 million, or $231 million. We do not have the 

money to spend wastefully. 

I supported the Medicare Prescription Drug Program. I voted for 

it. Not many Democrats did. I voted for it. A lot of people were concerned it was not going to be a good benefit. They did not like the 

way the program was crafted. They were afraid it would run way 
15 

over budget and that the folks who would use it would not like it. 

As it turns out, it has not run way over budget. And what does it 

cost? About $60 billion a year or so, something like that, a little 

more than that. And I think about 85 percent of the folks who use 

it like it. Those are better, favorable numbers than I have at home, 

and probably for my colleagues as well. 

Having said that, we have to figure out how to save some money 

in this program. We have to continue. Everything we do, we have 

to look at and say how do we save some money in this program. 

Ms. Lavelle has just given us a little bit of a to-do list here. What 

was the first one? And what I am going to do is ask everybody on 

the panel just to react to it and figure out who is responsible for 

doing that. I think the first one may involve some responsibility for 

us on this side of the dais. But go ahead, Ms. Lavelle, just go 

through the first one, and then we will have some discussion on 

each of these. 

Ms. LAVELLE. Sure. The first one was to establish a Restricted 

Recipient Program in Medicare Part D or a lock-in program. 

Chairman CARPER. All right. OK. Don’t we have that in Medicaid? Don’t we have that in most States in Medicaid where you basically say to someone who is thought to be maybe an abuser, they 

say ‘‘You are going to have one doctor—one pharmacy, you are 

going to have one doctor, and that is it.’’ And maybe that requires 

the assent of the Federal Government. I do not know that it does. 

It seems strange to me that we have that provision, a lock-in provision, in Medicaid but not in Medicare. 

So let us just talk—start off with Mr. Rannazzisi, your reaction 

to that recommendation. 

Mr. RANNAZZISI. Well, again, that is a little outside the scope of 

my authority, but—— 

Chairman CARPER. In that case, just be very brief. 

Mr. RANNAZZISI. As far as diversion goes, I think it is a fantastic 

idea. If I am not mistaken, that lock-in program is being used in 

Ohio, if I am not mistaken, and the Ohio Board of Pharmacy, the 

investigators, the Ohio Board of Pharmacy believe in that program. 

Chairman CARPER. I am told it is used in a number of States, 

not just Ohio but in a number of States, and we will find out how 

many. 

Mr. Blum, please? 

Mr. BLUM. I think that many State Medicaid programs do have 

a lock-in program. I do not believe that it is a Federal requirement, 

but I know that States on their own do put in place lock-in programs. The Part D program in its current construct runs the benefit through many different Part D plans, so I think this is an area 

that Congress would have to authorize. I do think it is time that 

Congress consider this change. I think the Congress would have to 

set out clear thresholds for which beneficiaries are required to be 

locked in, but we are happy to work with this Committee. And I 

think the Drug Utilization Review (DUR) Program that CMS put 

in place this year could serve as a model for which beneficiaries hit 

that threshold. 

Chairman CARPER. All right. Mr. Cantrell. 

Mr. CANTRELL. Yes, I think any legislation that would help us 

explore ways to prevent doctor shopping—and some of the patients 
16 

that we encounter in our cases actually are paid kickbacks to participate in these schemes. So in situations like that, I think we 

would be interested in exploring ways to prevent that kind of activity. 

Chairman CARPER. Mr. Wright. 

Mr. WRIGHT. I agree, and I think there may be two different 

kinds of lock-ins that are under discussion. One is to lock beneficiaries in a particular plan, and the other would be to lock them 

within a specific prescriber or pharmacy. We think that both of 

those should be considered. 

Chairman CARPER. All right. Good. 

What was your second point, Ms. Lavelle? 

Mr. LAVELLE. That was indeed the dual eligibles with evidence 

of drug-seeing behavior that bounce from one managed care plan 

to another on a monthly basis. And we at WellPoint are not allowed to tell Cigna or Aetna that someone that is coming from our 

plan is going to be a problem for them as well just because of the 

Health Insurance Portability and Accountability Act (HIPAA) requirements. 

Chairman CARPER. All right. What can we do within the constraints of HIPAA? Anyone, please, what can we do? 

Mr. BLUM. I think Congress can clearly provide greater authority 

for that data to be shared. I think there is always a balance between privacy and controlling payment, but this is another area 

that I would suggest that Congress can give more permission for 

that data sharing to happen. 

Chairman CARPER. All right. Thank you. 

What was No. 3? 

Ms. LAVELLE. The third was we support better coordination and 

cooperation among CMS, DOJ, and all stakeholders. 

Chairman CARPER. All right. Our friends from the OIG, react to 

that for us, if you would. 

Mr. CANTRELL. We are very much in favor of better coordination 

and communication. We are coordinating very well. We have the 

Health Care Fraud Prevention Partnership that has been established. It is in its infancy, but we are very much supportive of private-public data sharing and public partnerships where we can. 

Chairman CARPER. All right. No. 4? 

Ms. LAVELLE. The last one was to recommend that all expenses 

for health insurance anti-fraud and abuse programs be included as 

activities that improve health care quality in the medical loss ratio. 

Right now they are not. 

Chairman CARPER. Would you all react to that? Anyone. Who 

wants to react to that? Mr. Blum. Is it Dr. Blum? It is Mr. Blum, 

isn’t it? I always want to call you ‘‘Doctor.’’ 

Mr. BLUM. Thank you, but it is Mr. Blum. CMS believes, and I 

think it is consistent with the State insurance commissioners, that 

strong fraud and abuse is part and parcel to what a plan should 

be doing, that it is not part of benefit costs but it is the cost to run 

a well-managed program. CMS in its rules does permit collections 

to count toward the MLRs. We think we have found the right balance between requiring plans to set up procedures that is part and 

parcel to running a plan, but we do allow plans to count the collections toward the benefit side of the MLR. 
17 

Chairman CARPER. OK. Well, Ms. Lavelle, you have given us a 

pretty good start on a to-do list from our side, and this is one of 

those deals where there is work to be done on both sides, and not 

just the Federal Government, not just the legislative branch, not 

just CMS, but a bunch of us, including folks that are not in Congress and not at CMS. 

Dr. Coburn, thank you. 

Senator COBURN. So, Mr. Blum, let me just kind of get you on 

the record a little firmer here. CMS supports the modification of 

the Part D program to establish a lock-in? 

Mr. BLUM. What I can say to you, Senator, is that we have no 

official position, but I believe that it is time for Congress to consider this change. 

Senator COBURN. CMS does not have a position on that? 

Mr. BLUM. I am speaking for CMS, and I believe it is time for 

Congress to consider it, that it is not part of the President’s 2014 

budget submission, but I do think it is time for Congress to make 

this change. 

Senator COBURN. So would your recommendation back up the 

chain at CMS that would go along with Congress writing the bill 

that would do that? 

Mr. BLUM. Yes. And we are happy to support this Committee in 

that change. 

Senator COBURN. The second point: Would CMS also go back up 

the chain and support a loosening of the HIPAA rules so that insurers can protect patients and their long-term well-being by allowing them to transfer data on drug-seeking behavior patients? 

Mr. BLUM. I think one of the principles that CMS strongly believes is that we have to have greater data sharing to spot outliers, 

both beneficiaries, pharmacies, and physicians, and CMS would 

support that change. 

Senator COBURN. So if I wrote a bill that would allow just a little 

bitty hole for the insurance industry that is managing this to share 

the data on drug-seeking behavior to the next managed care plan, 

there would not be an objection from CMS to that? 

Mr. BLUM. We would have to see the details, obviously, but—— 

Senator COBURN. In principle. 

Mr. BLUM. In principle, yes. 

Senator COBURN. All right. Tell me, do you think that CMS gets 

$14 million worth of value a year from the MEDIC program? 

Mr. BLUM. I think the MEDIC program can be improved, and I 

think we want the MEDICs to be active, we want the MEDIC to 

be proactive, and the MEDIC is just one piece of a strong CMS 

oversight practice. But I do think that the MEDIC process can be 

improved, and to be more proactive and to take more action. 

I think data analysis is just one piece. It is what you do with the 

data. And we have to have action. We have to have many steps beyond just law enforcement action. But, I agree with you that we 

can improve the performance. 

Senator COBURN. So they had 21 referrals last year for $14 million for prosecution, and you just heard WellPoint talk about the 

hundreds that they have done in the last 6 months. Explain to me 

why we are not getting more value out of the MEDIC program. 
18 

Mr. BLUM. Well, my understanding is that the way the program 

works today, once the referral is made, it has to meet certain 

thresholds for law enforcement to take action. And what I think we 

want to see is the same problem that we have in the Part B program. There are different levels. And so for behavior that does not 

meet the law enforcement prosecutable threshold but is still outlier 

behavior, that I believe that the program should suspend that physician, move to paper claims, and the same kinds of processes that 

WellPoint talked about, CMS will be holding our plans and our 

contractors to that standard. But I think one change that we can 

consider is rather than having prescribers self-declare what their 

backgrounds are, according to the chart that was shown, to have 

them formally be enrolled in the Medicare program similar to Part 

B, and that is a change that we plan to make. 

Senator COBURN. When do you plan to make that change? 

Mr. BLUM. Well, typically we put out rules in the fall, and that 

is in process right now. 

Senator COBURN. So we are going to put out rules, so this time 

next year we might see a change? 

Mr. BLUM. My hope and my promise to this Committee is that 

in data for 2012–13 we will see a lower number than what the OIG 

found, and CMS will continue to make changes to our rules to 

bring that number down close to zero. But my hope is that given 

the changes CMS has made that I talked about, including requiring 

the Medicare Provider Inventory (MPIs) to be on the Part D claim, 

to holding our contractors to higher degrees of accountability, we 

will see lower numbers. And that will continue through further policy change and operational details. 

Senator COBURN. So I have no firm date. People are going to continue to die—right?—under this program. And we are going to put 

out rules in the fall. Why wouldn’t we put out rules now based on 

the recommendations of the OIG? 

Mr. BLUM. Well, I think we are taking action steps to respond 

to the OIG’s findings. So, for example, we have shared those pharmacies that are outliers with all our Part D plans for action today. 

CMS needs to balance the burdens that are going to be placed on 

prescribers who are not part of the Medicare program today that 

need to come into the Medicare program for validation and further 

oversight, and that is a process we cannot turn on overnight. We 

have to go through proposed rulemaking. But that to me is one 

more step the agency can take to achieve better results. 

Senator COBURN. You have plenty of paperwork to do; I understand that. Would you commit to this Committee, based on the recommendations of the OIG, to give us a report every 3 months for 

the next four quarters on where you are in complying with their 

recommendations since you readily accept that their recommendations are things you ought to do? 

Mr. BLUM. Absolutely. My understanding is that we have, and 

we are happy to commit to whatever process would be helpful to 

this Committee. 

Senator COBURN. And will you publish that report so that it does 

not just come to the Committee? 

Mr. BLUM. We will defer to how you want the report published. 
19 

Senator COBURN. Well, if we get it, I will make it public, because 

I think, one of our problems in government is we see a problem, 

and then our rules of government make it to where we cannot save 

the lives of the next 1,600 people who are going to die from a prescription drug overdose because we are not managing the Medicare 

Part D program through CMS effectively. And that is really not a 

very good excuse for us to—and I am not talking about you. I am 

talking about us, too—to wait until tomorrow to start making these 

changes, when you are talking about lives, you are talking about 

money. And you are also talking about not just lives that are 

snuffed out, you are talking about lives that are destroyed and people going to prison because we have made it easy to game the system. So I hope your commitments will be there. 

As you can tell from my opening statement, I am pretty disgusted with the MEDIC program because I do not think we are 

getting that much from it. And I plan on sending you a few letters 

and to the OIG to followup on that, because I do not think we are 

getting value out of the $14 million. And my hope will be that you 

will ride the contractors to where we actually get values and 

change the program to what it should be. 

My time is up. 

Chairman CARPER. Senator Chiesa. 

Senator CHIESA. Thank you, Mr. Chairman, and thanks to all of 

you for your testimony here today. 

I know from my experience as Attorney General what a catastrophic impact this epidemic has on the people that live in my 

State and I am sure throughout the country. What I do not appreciate as much is the impact it has on seniors and the different 

ways I think they are particularly vulnerable to people who are 

trying to game the system, as Dr. Coburn has talked about. 

And what I would like to find out—and I open this question to 

any of you who feel competent to answer it—is: What are the particular focuses on a population that is clearly vulnerable to this? 

They trust their doctors. They want to get better. Some of them 

have long-term illnesses that they are dealing with, and in some 

cases, it is just easier to try to medicate your way out of those illnesses than it is to try to talk with the family and get to the heart 

of what is going on. 

Are there relationships between, for example, assisted care facilities or nursing homes that are particularly problematic in this area 

that lead to this kind of abuse? 

Mr. WRIGHT. I do not know that I can directly answer the question, but with regard to the vulnerable population of the elderly 

being in nursing homes and some of these drugs being very powerful, we did do a review of antipsychotic drugs as used in the nursing home setting, and we found that 88 percent of them were prescribed against the black box warning, clearly raising health concerns. And based on the medical record review, we found 51 percent of the claims should not have been paid by Medicare. 

So when we did that kind of in-depth review in that vulnerable 

setting, we did, in fact, find substantial problems. 

Senator CHIESA. OK. Ms. Lavelle, we talked about doctor shopping as a part of this problem, and I know, again, in my own experience seeing some of the typical populations that engage in this 
20 

behavior, is that a problem? Do we see that among the senior population as well? 

Ms. LAVELLE. Frankly, when I speak of the doctor shoppers, the 

majority of what we are seeing are those that are under 65. They 

are dual eligibles, usually Social Security disability. We just referred eight cases last week, and all of them are under 65. 

Senator CHIESA. OK. And do you have any statistics or information that is available to tell us what percentage, or in your experience that you see, are over 65 that are engaging in this behavior? 

Ms. LAVELLE. I do not have any exact, but I can get that for you. 

Senator CHIESA. OK. Pain clinics and pill mills. Mr. Rannazzisi, 

I know that you are experienced with the DEA. Again, talking 

about the senior population, are they being exposed to a greater extent in those settings than we find other patients are? 

Mr. RANNAZZISI. I do not believe so. The pain clinic cases that I 

reviewed are generally a younger population of drug seekers that 

are going—remember, they are not going there, these rogue pain 

clinics, they are not going to get medical treatment. They are going 

to get medication to feed their addiction. So it is not really medical 

care. It is more of drug distribution illegally. 

Senator CHIESA. OK. And, Mr. Blum, I would like to ask you 

about the enrollment process. What factors do you think provide 

the greatest deterrence to keeping out the kinds of physicians that 

we do not want involved in these programs? 

Mr. BLUM. I think what we have learned from our fraud prevention system is that we have to do two things at the same time: We 

have to validate physicians’ credentials, and that has to be periodic. And one of the most important changes that the Congress 

made is to direct CMS to require this process. That is not true in 

the Part D program. There are many prescribers who are legitimate but are not formally part of the Medicare system. For example, dentists are one of the most commonly—frequent prescribers of 

pain medications. So I believe that every physician who is writing 

scripts for the Part D program needs to be enrolled in the Medicare 

system so we can validate. We are not reliant on self-reported databases. We can verify those who are truly massage therapists versus 

those who are just self-reporting as massage therapists. That is a 

change that I believe that the program needs to make. It is going 

to place new burdens on physicians, and I am sure this Congress 

will hear pushback from the physician community that it is burdensome, that for those prescribers that do not provide medical 

services that they should not be enrolled. But I do believe that it 

is time that we move to a different framework. 

Senator CHIESA. OK. Mr. Rannazzisi, we worked in New Jersey 

with the DEA to establish drop-box programs where people can 

take their unused prescription medications to those locations and 

get rid of them, no questions asked, in a secure location so that 

other family members cannot abuse them. In your experience, how 

effective do you think those programs have been at getting at the 

potential problem of the legitimately prescribed prescription drugs 

to a grandparent being then used inappropriately by one of the 

younger members of their household? 

Mr. RANNAZZISI. Well, we have taken the position that those 

medications, once they are expired or unneeded, need to get out of 
21 

that household. That is why we have these nationwide take-back 

programs. In April, we took in almost 376 tons of pharmaceuticals, 

the last take-back program. 

I think that we are in the process of drafting the final regulations for take-back, so we may have these drop boxes available 

across the country in certain authorized locations, and I think that 

will go a long way to preventing such tragedies as what we have 

seen in the past. 

Senator CHIESA. And nationwide, what percentage of the States 

participate in these programs, the drop-box programs? 

Mr. RANNAZZISI. Well, currently, the only drop-box programs that 

are allowed are ones in law enforcement facilities, either precinct 

houses or headquarters places. But I cannot tell you exactly how 

many because law enforcement agencies are exempt from the statute, so they could put their drop boxes in the facilities without reporting to DEA. 

Senator CHIESA. OK. But, anecdotally—I know, for example, we 

have talked about it actively in New Jersey—do you get the sense 

that many States are getting involved in these programs or not? 

Mr. RANNAZZISI. Yes. I believe quite a few States are getting involved in the program. Some States have their own program. I believe North Dakota has their own program now. 

Senator CHIESA. OK. Well, thank you. 

Thank you, Mr. Chairman. 

Chairman CARPER. Thank you very much. Dr. Coburn. 

Senator COBURN. [Presiding.] Mr. Blum, is CMS aware of actions 

by State medical boards and restricting of licensing or disciplinary 

procedures? 

Mr. BLUM. To some degree, but I think one thing that we need 

to do is to improve that data sharing. 

Senator COBURN. Does CMS share with providers—and I am 

talking insurance providers—when you have taken somebody off 

their eligibility to be able to prescribe, or treat Medicare patients? 

Mr. BLUM. That is a vulnerability that I concede that we need 

to do a better job, but—— 

Senator COBURN. But do you do it? 

Mr. BLUM. We will be doing it. 

Senator COBURN. But you do not do it now? 

Mr. BLUM. Not to the fullest degree. 

Senator COBURN. Do you ever give the other providers a list of 

problematic providers—I am talking insurance providers—a list of 

problematic people that are under review or that are under suspicion of being a bad actor? Do you ever share that information, not 

just the ones that have gone off but the ones that you are suspecting of fraud? 

Mr. BLUM. That CMS is? 

Senator COBURN. Yes. 

Mr. BLUM. One change that we have made, Senator, is that we 

now share those outlier pharmacies, for example, CMS will be expanding that list. 

Senator COBURN. How about outlier physicians? 

Mr. BLUM. That is going to be a change that CMS moves forward 

on. 
22 

Senator COBURN. You have to do a rulemaking on that? So there 

are some things that you can do immediately—— 

Mr. BLUM. Absolutely. 

Senator COBURN [continuing]. To share with the other providers, 

the Part D providers as well as other insurers. 

Mr. BLUM. And CMS pledges to this Committee that CMS will 

make those kinds of changes—certain changes require rulemaking, 

such as requiring all physicians to enroll in the Medicare program 

that prescribe through Part D. Some changes are management 

changes that CMS has and will continue to act on. 

Senator COBURN. OK. Ms. Lavelle, we just had this conversation, 

and in your testimony you said that plan sponsors are rarely informed of the ultimate result of actions that are taken and information collected by the agency is rarely shared with the private 

payers and CMS does not share information on revoked Medicare 

providers with private payers. You just heard, I think, some good 

news and a commitment to this Committee. 

WellPoint’s Special Investigation Unit refers every Part D case 

to the MEDIC, and WellPoint has the second highest number of referrals to the MEDIC. 

Ms. LAVELLE. That is correct. 

Senator COBURN. What have you seen from that? 

Ms. LAVELLE. That is one of the issues we have with the MEDIC. 

We are very collaborative with them, often refer cases over, but 

then we are never advised as to what type of action is ever taken. 

Senator COBURN. So that is something that needs to be fixed as 

well. 

Ms. LAVELLE. That would be very helpful to us. 

Senator COBURN. Mr. Blum, what do you think about that? 

Mr. BLUM. I think a small fraction of those cases that get referred to law enforcement are taken. Oftentimes there is a beneficiary who is complicit, and I think we all, the Federal Government, are hesitant to take action against beneficiaries who are 

complicit. I think it is time that we change, and I think it is time 

that we share that information. I think it is time that we hold the 

Part D MEDIC to a higher degree of accountability. And I think 

part of the issue is that the process now relies on that referral to 

be taken by law enforcement, but that is not sufficient. 

Senator COBURN. Well, just because they choose not to prosecute 

does not mean somebody has not violated the law. 

Mr. BLUM. Correct. 

Senator COBURN. And it does not mean somebody should not be 

banned from having Medicare provider status. So you agree with 

that? 

Mr. BLUM. I do. 

Senator COBURN. How often do you see Medicare participants 

running in this program as far as pill mills? It was asked a little 

bit ago by my colleague from New Jersey, but how often are older 

patients used as part of the scam, not wanting the drugs but buying the drugs, using their Medicare number and their provider to 

get the drugs? How often are we seeing that? 

Mr. CANTRELL. More and more we see that they are not even 

aware that this is happening. Through identity theft, their bene-
23 

ficiary numbers are used to bill Medicare, and they are not even 

aware of it. So that is often the case. 

Similar to the DEA and WellPoint’s experience, we see lots of 

younger beneficiaries involved in some of the pill mill-type investigations who are interested in getting the drugs. 

Senator COBURN. So all you have to have is a Social Security 

number, right? 

Mr. CANTRELL. In essence and another letter that you tack on 

the end. 

Senator COBURN. Yes, which you can fraudulently provide. So 

that is another reason why we should take Social Security numbers 

off the Medicare roll since that is what is at risk. 

Mr. Chairman, thank you for this hearing. I have to be on the 

floor, but I would just tell you, we need, our staff needs to followup 

on this. We have a commitment from Mr. Blum in terms of quarterly reports on the OIG’s recommendations. My hope is that they 

make great changes, and I look forward to working with you on two 

things that I think we can write very simple legislation and solve 

some problems. 

Chairman CARPER. [Presiding]. You bet. Thank you, Dr. Coburn. 

I want to back up just a little bit. We have been talking about 

what we can do in the legislative branch, what you all can do at 

CMS, what we can do in the law enforcement community. We have 

not talked at all about the roles of parents in this, and parents or 

family members, extended family members, talk a little bit about 

that. And are you aware of some States or some communities that 

are doing an especially good job in that kind of parental involvement or family involvement? Anybody know? Because it cannot just 

be the government. When it is all hands on deck, we mean all 

hands, including the hands of parents. 

Mr. WRIGHT. When we did the work on antipsychotic drugs that 

I referenced earlier, we certainly made as part of that story that 

families needed to be more involved, especially when beneficiaries 

are in nursing homes and families are not necessarily aware of everything that is being prescribed on their behalf. We did very much 

make the point that this was something where everybody needed 

to contribute to correct. 

Chairman CARPER. Others? Raise your hands. How many of you 

are parents? OK. Everybody. You can speak. You do not have to 

have your professional hat on. You can put on your parent hat if 

you want. 

Mr. BLUM. I think from a Medicare perspective, Medicare beneficiaries take many drugs, and I think the average is 12 scripts per 

beneficiary right now. I think Part D plans do a lot to do 

polypharmacy reviews. That is not sufficient. Beneficiaries themselves, we encourage through the annual new wellness visit that 

Congress authorized in the Affordable Care Act (ACA) that medication be part of the annual wellness visit. And I think having the 

independent screen and check on the multitude of prescriptions 

beneficiaries take is one important step in the overall process. 

I do think there are voices here that should be at this table to 

speak to overprescribing, I think having the physician community 

to get much more engaged, I think having the pharmaceutical manufacturers getting much more engaged. One of the reasons that 
24 

payers are seeing so much growth in these medications is because 

the marketplace is being flooded, if you will, with these medications. And so payers can only do so much, beneficiaries can only do 

so much, Congress can only do so much. But there are other voices 

that I think need to be part of this conversation—the physician 

community, the pharmacy community, pharmaceutical manufacturers—to ensure that a multifaceted strategy is developed. 

Chairman CARPER. I do not think I heard you mention parents. 

Mr. BLUM. Parents, too. Absolutely. 

Chairman CARPER. Go ahead, anybody else, please. Mr. 

Rannazzisi? 

Mr. RANNAZZISI. I think one of the biggest problems we are encountering right now is that parents do not understand the dangers 

of these drugs, and they are not talking to their children about 

these drugs. Just 2 years ago, we attempted to do a parents program at the second largest school district in the country. We made 

sure that it was adequately marketed with e-mail blasts and news 

reports, and we had 11 parents—or 14 parents show up to a huge 

venue. 

I am not so sure that they understand and I am not so sure parents are willing to understand how bad these drugs are and how 

bad the abuse of these drugs are. We work with community coalitions all the time. We partner with community coalitions on the 

take-back programs. We hand out literature. We try to go to every 

community meeting that we are invited to, to present. But in the 

end, I think you are right; if the parents do not get involved, we 

are going to see tragedy over and over again. 

Chairman CARPER. All right. Others, please? Anybody else? Ms. 

Lavelle. 

Ms. LAVELLE. I had a daughter who was a lacrosse player, tore 

her ACL. She had surgery, was sent home with a script for 

hydrocodone, and her first day back in school as a sophomore she 

had several students approach her and asked if they could buy her 

pills. So it is in our backyard, and it is very insidious. 

So we went in the school and did some parent-teacher conferencing and we actually partnered with FBI and DEA agents and 

did some awareness type of workshops, because even if you have 

a babysitter over, they look in the prescription cabinet now, it is 

that pervasive out in society right now. 

Chairman CARPER. Any other parents want to say anything on 

this one? Mr. Cantrell. 

Mr. CANTRELL. Yes, I think it is education and outreach to parents, as Mr. Rannazzisi has mentioned before. I think we would 

welcome the opportunity to join them in some of these outreach efforts, whether they be parents or the prescriber community. I think 

that is the front line of defense in preventing these problems from 

happening in the first place. 

Chairman CARPER. The good news here is that parents maybe do 

not have to worry as much about their kids being on heroin or 

maybe they do not have to worry as much about their kids being 

on cocaine or Ecstasy. The bad news is, as you say, this is pretty 

insidious. 

One of the reasons why we are having this hearing is to figure 

out what we can do collectively, folks in law enforcement, CMS, in-
25 

surance companies, providers, the PBMs, the legislative branch, 

what we can do. But we also need to send a message to parents. 

It is not good. It is not good for our kids. I say that as a father 

of three boys—men—and the parents just need to get their heads 

wrapped around this and understand what is going on here. And 

they have an obligation here as well. The government cannot just 

do it all. We have to be a partner, but they have to be a partner 

as well. 

I want to go back to some of the steps that CMS has already 

taken, steps that you have taken, steps you are about to take, and 

then the third area would be steps that are called for in the President’s 2014 budget proposal. Can you just briefly run through 

those? What have you already done that you think is helping? 

What are you about to do or are undertaking? And, finally, what 

would you like to do under the President’s budget? 

Mr. BLUM. So I think a couple of things. I think our focus so far 

has been to put in place our requirements for our Part D plans to 

do much more comprehensive drug utilization reviews, that it is 

not sufficient to just simply look at the point-of-sale pharmacy 

claim, you need to do the complete look over the course of a year 

to see the full spectrum of beneficiaries’ uses. 

For those beneficiaries that exceed a certain clinical threshold, 

we require the Part D plans to contact the patients’ physicians to 

make sure they are being well managed. If they are not, then Part 

D plans are expected to put in place point-of-sale edits on those 

beneficiaries that could be doing drug-seeking behaviors. 

CMS, consistent with changes in the law and changes that this 

Committee has urged, now requires every drug claim paid by any 

Part D plan to have the provider’s number on it so we can track, 

we can do analyses, we can verify that those scripts are legitimate. 

We also hold our Part D plans to a higher degree of accountability. 

That is the current work that we are doing. 

In addition to the outlier analysis that we are now sharing with 

our Part D sponsors and other stakeholders, CMS is moving to new 

areas. So I do believe that it is time for us to build a bigger universe of oversight on all prescribers, not just those that bill the 

Part B program but all prescribers in the Part D program as well. 

CMS will be upholding our MEDIC to a higher degree of accountability, but also giving it greater authority to do much more intensive reviews with PBMs, pharmacies, and physicians to do more 

comprehensive looks. 

The President’s budget has called for ways to promote greater 

Part D data sharing. I think one of the limitations right now with 

State monitoring programs is they are all separate systems that do 

not talk to each other. We know that drug-seeking behavior crosses 

State boundaries. We know that it crosses health insurance plans. 

Many are cash-paying customers, so Part D changes alone will not 

stop the cash-paying customers. 

One proposal in the President’s budget is to provide greater assistance to drug monitoring programs run by States to share data 

and build common data sets. 

Chairman CARPER. Thank you. 

A couple of questions, if I could, for Mr. Rannazzisi and Mr. 

Cantrell, and these pertain more to the law enforcement side, and 
26 

I know you and your agencies are doing a lot to identify, to investigate, and to try to bring to justice those that are defrauding 

Medicare. 

But let me just ask you if you could comment on some of the 

challenges facing law enforcement and some of the steps that, 

whether it is Congress, whether it is the Centers for Medicare & 

Medicaid Services, or, frankly, others, steps that we could take, individually, collectively, that would help you and your colleagues in 

your work. So that would be the first question. 

Second, the followup, can law enforcement alone curb the diversion and the abuse of prescription drugs? I think obviously not, and 

we have already talked about that. This is all hands on deck, and 

it includes not just you sitting at the table and others; it includes 

us and it also includes parents and families. 

But let me just go back to the first question. What can those of 

us at CMS, those of us in the legislative branch, or maybe within 

the Administration do to provide some help for you in your work? 

It is a little bit like swimming against the tide, I think. 

Mr. RANNAZZISI. As an investigator, one of the most frustrating 

things I see is when there are tools available to the registrant community, the prescribers and the dispensers, and they are not using 

them. They could help us in the long run by just using those prescription drug monitoring programs (PDMPs). If there is any way 

Congress could push the States to do that, because right now some 

very good programs have less than 15 percent of the prescribers 

using them. 

Chairman CARPER. Why do you think that is? 

Mr. RANNAZZISI. There are all sorts of reasons. One of the reasons I always hear is, ‘‘I do not have enough time.’’ And that statement tells me you do not have enough time to provide patient care, 

because in the end this is just like another diagnostic tool. 

Wouldn’t you want to know if your patient is seeing two or three 

or four different doctors? Wouldn’t you want to know if you are prescribing methadone and you have two other doctors prescribing a 

depressant, a benzodiazepine, two drugs that might affect how the 

drug is distributed in the body, how it is eliminated? Wouldn’t you 

want to know that? 

It seems to me that if this tool is available—and in 49 States 

right now we have either PDMPs or an infrastructure in place, legislation in place to create a PDMP, that as a practitioner, be it a 

mid-level practitioner, a physician, or a pharmacist, you would 

want to know what your patient is doing. 

Mr. Blum is absolutely right. It is not just payments through 

Medicare. These people might be getting payments through Medicare, and they are also paying cash. And if you are a true doctor 

shopper, you are going to go to five, six, seven doctors at a time 

for the same illness. If I was that practitioner, I would want to 

know exactly what that patient is doing. Yet in many States, with 

the exception, I believe, of New York, Kentucky, and I believe Tennessee now has mandatory review of the PDMP before prescribing. 

The other States, they are just not using them. 

Chairman CARPER. OK. Anyone else? Mr. Cantrell, do you want 

to respond to that as well, please? 
27 

Mr. CANTRELL. Well, we certainly agree that we should explore 

increased utilization of prescription drug monitoring programs and 

even the potential for a lock-in to stop the overprescribing and the 

doctor shopping that is taking place. We have seen people leave the 

State, cross State lines in order to find places where it is easier to 

get the drugs. We see that fairly routinely in our investigations. 

And we are also very encouraged by some of the data sharing and 

additional data analytics that Mr. Blum has committed to today, 

and we think that is going to pay dividends down the road as well. 

I would like to mention that our office, which is responsible for 

overseeing this huge program, is shrinking in the face of the 

growth in Medicare and Medicaid. Based on some expiring funding 

streams, we are set to lose roughly 400 bodies out of a total of 

1,800 at our peak in 2012. And that is really limiting our ability 

to expand our oversight in some of these areas. 

Chairman CARPER. That is a reduction from 1,200 to 400? 

Mr. CANTRELL. Excuse me, 1,800 to around 1,400. 

Chairman CARPER. And, again, the reason for that is what? 

Mr. CANTRELL. Some expiring funding streams. Certainly sequestration has added to that. But before sequestration, we were already facing expiring funding streams through the Medicaid Integrity Program and others. So we are operating with a reduced budget in the face of the growing program, and just last year alone, our 

office closed down 1,200 complaints due to lack of resources. Those 

are complaints that came through the door that we did not have 

the resources to investigate further to determine whether it was a 

viable criminal case or not. And that number does not appear to 

be going down. 

Chairman CARPER. OK. The next question I have is really for the 

entire panel, and it focuses on State efforts to combat prescription 

drug abuse and diversion. Some of you have mentioned in your testimonies today the serious efforts being made to combat prescription waste and fraud at the State level. We just talked about it 

here again. For example, the prescription drug monitoring programs established and operated by State governments have had a 

fair amount of success in rooting out fraud in Medicare as well as 

Medicaid and in the private sector. These monitoring programs 

track prescriptions filled by pharmacies across a State in order to 

help identify and prevent illegal diversion or abuse. 

I was encouraged to hear from today’s testimony that 46 States 

have operational monitoring programs and an additional 3 States 

have enacted legislation to establish one. I think when we first got 

into this issue a couple years ago, we found out that there are a 

lot more States that did not have this kind of monitoring program. 

One of them was my own State, and to the credit of our Governor 

and the legislature, they jumped all over it. But that is the good 

news. I think it was not that long ago, maybe 4 years ago, maybe 

two-thirds of the States, maybe about 33, 34 of the States had 

these programs operational. 

Could each of you today just comment on the importance and effectiveness of the State-run prescription drug monitoring programs 

in combating prescription drug waste and fraud? And, also, what 

are some of the important next steps to ensure that the monitoring 

programs become, over time, even more effective? 
28 

Ms. Lavelle, do you want to go first? 

Ms. LAVELLE. Sure. One of our biggest pain points in WellPoint 

is a little corner of the State of Virginia known as Roanoke. 

That—— 

Chairman CARPER. ‘‘Star city of the South? ’’ 

Ms. LAVELLE. Yes. 

Chairman CARPER. Where I grew up. 

Ms. LAVELLE. Really? 

Chairman CARPER. In Danville and Roanoke. 

Ms. LAVELLE. Oh, my goodness. We have pharmacies where we 

often see up to 15 license plates from outlying States. We know 

that they are pill mills. We know that they are impacting Part D 

and our commercial plans as well as our Medicaid plans. And we 

have been working with the State law enforcement agencies to get 

them prosecuted. We have been pretty successful in a lot of referrals, but it is, again, a major problem in that part of the State of 

Virginia, and we are really focusing on that. 

Los Angeles County is our other hot spot and—— 

Chairman CARPER. Why do you suppose Roanoke, Virginia, 

would be a hot spot? I could see maybe L.A., but why—— 

Ms. LAVELLE. We have often asked that, and maybe the gentleman from DEA knows more than I. But I have often been told 

that it is a spillover from the coal mining days. It is hard to say, 

but we have a real pain point in that part of the world. So we are 

trying to lock in as many as we can in the Medicaid program and 

to refer all the pill mills for prosecution. 

Chairman CARPER. And when you are referring them for prosecution, who do you refer them to? What entity do you refer them to? 

Ms. LAVELLE. It depends. Usually the State troopers, Virginia 

State troopers will pick up those cases. The U.S. Attorney’s Office 

has taken quite a few of the pain management providers, which we 

often refer to as ‘‘drug dealers in white lab jackets.’’ Some very 

egregious. We have even had calls from the coroner’s office advising 

us that the 14th body has come in from a particular prescriber, and 

they did not know who else to call, but they knew they had Blue 

Cross insurance. So it is that big of a problem there. 

Chairman CARPER. OK. Thank you. Mr. Wright. 

Mr. WRIGHT. In terms of next steps, we do plan additional evaluation work looking at Medicaid drug utilization review programs. 

That is not something that we have directly reviewed at this date, 

but we are planning on doing reviews that will determine how they 

operate, how they are reviewed, which ones are effective. We think 

this is an important place for us to go, building on the work that 

we have discussed today. 

In addition to that, we continue to look at issues associated with 

Medicaid data overall. It is very important from a national standpoint that there be complete and accurate Medicaid data, which 

historically there have been difficulties in building. So we plan on 

continuing to work on that issue, hopefully getting to the point at 

a future date when we have a comprehensive Medicaid data set 

that will enable us to look at Medicaid holistically and not just 

State by State. 

Chairman CARPER. OK. Thank you. Mr. Cantrell. 
29 

Mr. CANTRELL. I will just reiterate that we think that the prescription drug monitoring programs do serve in many States as a 

great deterrent to this type of activity, and if all States had a similar level of program, then we might prevent some of this crossing 

State lines in order to avoid them. 

I will also just mention that we have the Medicaid Fraud Control 

Units, who we work with quite frequently, and their involvement 

in this effort is also important. 

Chairman CARPER. Thank you. Mr. Blum. 

Mr. BLUM. I think given the steps we are taking at CMS to reduce the probability that Part D is paying for inappropriate medications, I do not believe that is going to stop the problem. I think 

the drugs are very inexpensive, and if CMS takes further steps to 

bring the rate down to zero, those shift to cash-paying transactions, 

which means that other data sources will be necessary to spot 

drug-seeking behaviors, and I think that the State drug programs 

provide a tremendous resource. Data has to be shared. Data has to 

be cross-analyzed because beneficiaries and schemes do cross State 

lines. But just focusing on the Part D program will not solve the 

problem given the cost of these drugs. They are very inexpensive 

and they will just shift to cash. 

Chairman CARPER. All right. Thank you. Mr. Rannazzisi. 

Mr. RANNAZZISI. Again, going back to the PDMPs, one of the 

most important things involving the PDMPs is Internet 

connectivity between the States. If the States are not interconnected, you are not going to get a full picture of doctor shopping. The National Association of Boards of Pharmacy is currently 

connecting States. I think they have 15 States interconnected right 

now. That way it prevents these people from going cross-border. If 

you are going cross-border from Indiana to Kentucky, Kentucky to 

Ohio, it will show up on your PDMPs. 

As far as why the pill mills are going into rural areas, it is because they are comfortable there. Pill mills, when they started in 

Florida, were very comfortable because Florida did not have a 

PDMP and they did not really have a regulatory infrastructure to 

prevent them from spreading. As soon as law enforcement, the regulatory infrastructure in the State of Florida started passing statutes, they felt heat and started to move. They moved up into Georgia, rural areas off I–75. Now Georgia is giving them heat, and 

they are up in Tennessee. They move to rural areas because they 

are comfortable because they do not believe that law enforcement 

and the regulatory bodies will find them in those rural areas. It is 

not that those areas have a lot of pain patients. It is that this is 

where they are comfortable. And you are absolutely right. If you 

look at a very active pain clinic, a rogue pain clinic, you are going 

to see license plates from all over the place. When we were doing 

the Florida pain clinics, there were license plates as far as Massachusetts down into Florida. 

And you made one other statement before about heroin and parents not having to worry about heroin because of prescription 

drugs. The fact is that we are seeing more and more throughout 

the country where children, young adults, cannot afford the prescription drugs anymore, because, remember, the street value for 

hydrocodone is only $5 or $7, even the oxycodone combination prod-
30 

ucts, $5 to $7 a tablet. But when you start talking about the singleentity, 30-milligram, immediate release oxycodone 30s or 

OxyContin or oxymorphone, you are talking between $30 and $80 

a tablet. And once you are addicted, you cannot afford that, especially if you are on multiple tablets a day. So what we are seeing 

throughout the country in both rural and urban areas is kids moving to heroin, and that is well documented, both in the literature 

and by law enforcement reports. Heroin is going to be a problem 

if we do not get a handle on the opiate abuse in the United States. 

Chairman CARPER. OK. Can I followup, Mr. Rannazzisi, with 

maybe another question? But before I ask this, I am going to telegraph a pitch, if I could here. One of the things sometimes I will 

do with a hearing of this nature is ask not only the witnesses to 

give an opening statement, but ask you to give a brief closing statement, not a 5-minute statement but just a brief closing statement. 

If there are some points you want to reiterate, that would be fine. 

If some of the other witnesses have said something that you think 

needs to be seconded or re-emphasized, or if there are some things, 

you have some advice for us on this side of the dais, again, we 

would welcome that, but just some closing thoughts that you think 

ought to be mentioned, either for the first time or re-emphasized, 

that would be helpful. 

But, Mr. Rannazzisi, I am interested in learning a little bit more 

about the steps that DEA takes to ensure that its registry of practitioners authorized to prescribe controlled substances is accurate 

and up to date. A key preventive step for curbing fraudulent diversion of controlled substances such as OxyContin is, I am told, to 

maintain an accurate list of those physicians that are authorized 

to prescribe in the first place. But, obviously, there are some challenges. 

For example, I understand that the DEA only has access to a less 

than complete list of people who have died. There is something 

called the Death Master File (DMF), and you have access to the 

public file but not the more complete file that is maintained by the 

Social Security Administration (SSA). And I would just ask what 

steps does the DEA take to ensure that the registry of controlled 

substance providers is accurate and up to date? And are there some 

additional steps that are under consideration, perhaps some that 

might need congressional support? 

Mr. RANNAZZISI. I believe that we are bouncing our system off 

the Social Security death registry. I have to go back and look now 

because I thought we were looking at the complete system. But if 

we are looking at a partial system and not getting the information, 

I would like to get back to the Committee. 

Chairman CARPER. If you would. I am told you have access to the 

public file, but not to the more complete file that is maintained by 

the Social Security Administration. So if you could followup on 

that, and we will ask you to respond in writing, if you would, 

please. 

Mr. RANNAZZISI. Yes, sir. 

Chairman CARPER. OK. 

I have a short closing statement of my own, but before I offer 

that, I am just going to go back to our witnesses. And thank you 

for being here. Thank you for your work in these vineyards. This 
31 

is not an easy one, is it? It is not an easy one. And none of us has 

the solution or the ability to—there are no silver bullets here. A lot 

of silver BB’s. And we have to make sure that we identify them 

and that we are putting them to good use. 

Ms. Lavelle, do you want to give just a brief closing statement, 

just a minute or two? 

Ms. LAVELLE. Sure. I appreciate Mr. Blum’s words, and they give 

us great hope that we are going to have some changes in the future. I also appreciate the work that HHS and the Fraud Prevention Partnership has been doing. We have people in the room here 

that have been instrumental in bringing the privates and the 

publics and the agencies together, and I have great hope that we 

will have a very successful partnership going forward. There is a 

great deal of promise there, but we have work to do. 

And, second, I wanted to reiterate and point out that the paradigm is changing for WellPoint. We no longer want to pay and 

chase. In doing so we get 20 to 30 cents back on the dollar. The 

paradigm for us is prevention and to stop the dollars from ever 

going out the door. 

So, with that, I want to point out that with the medical loss ratio 

we are only allowed credit for collections, which is counterintuitive 

to our new paradigm of savings. So it actually encourages recoveries because that is the only credit we get. So with our new paradigm, we hope that there may be some changing activities in the 

MLR that will give us credit for some of the work we do and the 

tools that we use. Thank you. 

Chairman CARPER. Thank you for that point. Thank you. Mr. 

Wright. 

Mr. WRIGHT. In closing, I think I would like to make three 

points. 

One, it is extremely important to follow through and implement 

the recommendations that have been made by our office. I would 

specifically mention recommendations aimed at the sponsors. For 

example, we have recommended that the sponsors be required to 

refer fraud and abuse cases to the MEDIC. Currently that reporting is only voluntary. 

There are a series of recommendations aimed specifically at the 

MEDIC in terms of their ability to get information from sponsors, 

pharmacies, and prescribers that they do not currently have. There 

are recommendations pertaining to the MEDIC in terms of doing 

more proactive data analytics. And, last, I think just in general, revamping and strengthening the MEDIC function is really crucial to 

what we have been talking about today. 

The second point that I would reiterate is the resource issues 

that Gary raised. Fully funding the office in terms of the President’s budget request is crucial for our oversight activities. As Gary 

mentioned, we are slated to be down 200 staff by the end of the 

year and are on track to attrit 400 staff by the end of 2015. The 

office likes to point out that we return $8 for every dollar invested 

in us. To the extent staff leave, they will no longer be contributing 

to that return on investment. 

And the third and final—— 
32 

Chairman CARPER. Stop right there if you would. So the President’s budget, you are urging us at least in this respect to support 

the President’s budget? 

Mr. WRIGHT. To fully fund the President’s budget, correct. 

Chairman CARPER. OK. Thank you. All right. 

Mr. WRIGHT. And, last, conducting oversight hearings, as you 

have done today, is really crucial to shedding light on these problems and getting all the players aligned to actually do something 

about them. 

Chairman CARPER. All right. Thank you. Mr. Cantrell. 

Mr. CANTRELL. First, I want to thank you, Chairman Carper, for 

holding this hearing. I think it is a great opportunity for us all to 

talk and identify potential solutions. And Mr. Wright has already 

mentioned the resource issue, so—— 

Chairman CARPER. You can mention it again. Seriously. Repetition is good. 

Mr. CANTRELL. Well, I will say real quick, you may have heard 

of the Health Enforcement Action Team (HEAT) and our strike 

force teams that have tackled Medicare fraud in nine cities across 

the country. It has been a very successful model in tackling all 

types of Medicare fraud. We would like to be able to expand that 

kind of focus in other areas of the country and other areas of the 

program. And I think with additional resources that are included 

in the President’s budget, we would be able to do that sort of thing. 

And while prescription drug fraud and abuse is a top priority for 

OIG now, I know that there is more that we can do with more 

boots on the ground. 

Chairman CARPER. OK. Thank you. Mr. Blum. 

Mr. BLUM. I want to thank the Committee for holding this hearing. CMS welcomes the oversight. Oversight helps us build programs that better serve beneficiaries. And I think it is true that 

when the program was established back in 2006, the focus was on 

making sure beneficiaries got every drug they needed. And a lot of 

the oversight work that CMS has done was to make sure that 

beneficiaries get what they need at the point of sale, and that was 

appropriate at the time. 

But now we are in a different time, and I think now the focus 

should be making sure beneficiaries get what they need, but stopping those payments for the prescribing that is inappropriate. And 

that will take some further steps—will build on current actions but 

take some further steps. It will create more friction that you will 

hear about from the physician community, from pharmacies, and 

from beneficiary themselves. I think that is something that, in addition to changes in law, I think the programs will need your support once that friction starts. To enroll all prescribers to the Medicare program will take a huge lift, and you will hear about it. 

And I think one request that we do have is that Congress continue to support these changes, but we are going to have to create 

more friction in the system to kind of shift the paradigm from not 

just providing all drugs at the point of sale, but to hold everyone 

accountable, CMS too, to stopping those drugs that are not appropriate. 

Chairman CARPER. All right. Thank you. Mr. Rannazzisi. 
33 

Mr. RANNAZZISI. Finally, Mr. Chairman, I want to thank you and 

Senator Coburn for your leadership in this area and to get the 

word out about the use of these drugs. 

I also want to thank you for identifying education of parents and 

family members as being an important part of our overall strategy 

because, quite frankly, there are not too many people that understand that because it does not really affect them until it actually 

affects them, and then it is too late. 

I look forward to working with colleagues at HHS, continuing to 

work in CMS as we move forward against these people who are basically gaming the system and doctor shoppers and people who are 

just diverting. 

And, finally, when you talk about sequestration, it is problematic 

for us too. We are losing positions through attrition, and we cannot 

fill those positions right now, especially in my scientific staff and 

my regulatory staff and our special agents. 

Thank you very much for this opportunity. 

Chairman CARPER. Thank you, each of you, for those closing 

statements. I was not going to mention this, but I am going to. Dr. 

Coburn has put in a lot of time and energy over the last several 

years in helping to develop a comprehensive deficit reduction plan 

which involves roughly $1 of revenue, additional revenue for every 

$3 on the spending side, and it is a balanced plan put together 

under the auspices of Erskine Bowles and former Senator Alan 

Simpson, and it is something that I support as well, as do a number of my colleagues. The President’s latest budget proposal for 

2014 actually mirrors and looks a whole lot like the efforts of the 

Simpson-Bowles Deficit Commission. 

One of the virtues that it would have if it were adopted, if something like that were to be adopted, is we would end sequestration. 

We would also put ourselves on a track to reduce the deficit by another roughly $5 trillion over the next 10 years. It does not balance 

the budget, but it gets us certainly a lot closer to where we need 

to be. 

In response to your urging for us to be mindful of sequestration 

and what it does in terms of your abilities to do your jobs, I just 

want you to know, there is a pretty good plan out there, and the 

President actually seems to be lined up behind it now, and my hope 

is that we can before the end of this fiscal year actually do that 

or do something very close to that. 

That leads me to this statement. I have already said it before. 

We still have huge budget deficits, about over $600 billion. That is 

better than $1.4 trillion, but we still have a ways to go, and it looks 

like the deficit might continue to go down for a while and then 

come back up again. The big driver of this is my generation, the 

boomers, and as we move into Medicare and other programs, we 

are needing greater Federal assistance. 

As a result, if we are going to be serious on deficit reduction, it 

has to include Medicare, not in a thoughtless way, not in a way 

that savages older people or poor people, but in a way that actually 

saves some money. And it uses a lot of common sense, it uses technology, and saves these programs for my kids, for your kids, and 

for our grandchildren as well. 
34 

On the other side of that, Medicare is not running a big surplus 

these days. In fact, Medicare, given the tidal wave of boomers that 

are moving into a time in their lives when they are eligible for 

Medicare and other programs, is looking to eventually run out of 

money in the next decade, and that is not good. 

So we attack on this Committee a lot of issues on a fiscal basis, 

and we look at why we are wasting money, it makes the deficit 

worse, it makes it hastens the day when Medicare runs out of 

money. But this issue has another more human side that we have 

heard here today. And when you talked, Ms. Lavelle, about your 

daughter, a lacrosse player, injured, going back to school, taking 

the controlled substance for pain control, and having other students in the schools saying they would like to buy some of her 

extra pills, that really brings it home. 

And as good as you and the folks at WellPoint are in the work 

that you do in these vineyards, and our friends from the Inspector 

General’s office and Jonathan Blum and the people at CMS and 

folks from DEA and our efforts here, it is not enough. Any one of 

us by ourselves cannot do it. This is, as I like to say, an old Navy 

guy, all hands on deck. It is a shared responsibility, and we have 

to all be part of this team. 

We have the benefit of having some technology today that we did 

not have that many years ago, and I can remember—my mom is 

deceased now, but she passed away about 6 years ago. She lived 

down in Florida for most of the last 30 years of her life. She had 

I think about six different doctors that were prescribing 15 different medicines. None of them ever talked to each other. They did 

not know that the others were prescribing medicines for her. And, 

unfortunately, she was not unique, and that happened a whole lot. 

But we figured out in that situation that a Medicare patient, was 

receiving medicines that were not compatible with one another. 

And we have just gone way beyond that in terms of our technology 

and our ability to know what is going on in those situations. 

In this Committee we spend a fair amount of time on homeland 

security, the other piece of what we do, and there is a lot of discussion in the media and across the country about what the National 

Security Agency is doing in terms of telephone calls or electronic 

messages over the Internet, and in an effort to try to make sure 

bad people do not come in and do harm to us. And we have folks 

that are hacking into our systems as we gather here today, and 

there is a real tension between how do we protect our privacy, our 

rights as individuals, and how do we protect ourselves and our 

country from attacks, whether they be from terrorists or whether 

they be from cyber terrorists. 

Having said that, the kind of tools that are available to protect 

our personal safety and our national security and protect us from 

cyber attacks, the technology is pretty amazing. And I think we are 

only scratching the surface in terms of what we can do in a way 

that is respectful to privacy rights to better harness technology, to 

identify whether it is a doctor, whether it is one of these pill mills, 

or whether it is a massage therapist—nothing against massage 

therapists—whether it is a dental hygienist—nothing against dental hygienists—but we want to make sure that they are prescribing 
35 

what is appropriate, what is lawful; and when they do not, that we 

have the ability to detect that and do something about it. 

The last thing I want to say is this: Parents have to get their 

heads in the game. Most kids grow up in a home where they have 

at least one, oftentimes two parents that really care about them, 

love them, and want to make sure they are making the right decisions and the parents are setting the right kind of examples. The 

government cannot do this by itself. We need to be helpful. We 

need to be supportive. We need to play our role, and we have a big 

role to play. But so do parents and family members, and they need 

to get their heads in the game. And my hope is that holding a hearing like this not only helps to encourage all of us that have these 

responsibilities to work on these problems; my hope is that the 

word will get to a lot of homes across the country where parents 

are not as mindful as they need to be and remind them that they 

have a responsibility as well. They have a whole lot at stake as 

well. 

We have a pretty good to-do list here for us on this side and for 

you on the other side of the table. Thank you for helping us put 

that together, for the work that is being done. And as I like to say, 

everything I do I know I can do better. And as I learned from my 

father as a little boy growing up in Roanoke, Virginia, I learned 

that if it is not perfect, make it better. That is what I learned: This 

is not a perfect situation. We are doing better in some respects, and 

we can do a whole lot better, and we need to. 

With that, this hearing is almost adjourned, and I am told by 

this young lady over here on the left who is going to be retiring— 

in how many days? Four days. Trina is going to be retiring. She 

has been our chief clerk for a lot longer than you would imagine. 

Looking at her, it is hard to believe she is eligible to retire, but she 

is. And we appreciate very much her work. I do not know if we are 

going to have another hearing before you step down. I know we are 

going to have a business meeting here later today and try to put 

out some of the President’s nominees. I just want to say in front 

of you and those who have admired your work for many years, 

Trina, how much we admire you and respect you and are grateful 

for your service not just to this Committee, not just to the Senate, 

but really to our country. 

And with that having been said, the hearing record will remain 

open for 15 days—that is until July 9 at 5 p.m.—for the submission 

of statements and questions for the record. 

And I would just say to our guests, three of us were here today. 

A number of staff were here as well. As I said earlier, we have a 

vote that starts at 5:30. Members are flying in from all over the 

country, from their own home States. And the fact that there are 

not more Members here, do not be discouraged by that. I am not. 

You should not be either. Dr. Coburn and I and our new Member 

from New Jersey, he is going to be good. I think he is in office until 

at least October or so. Maybe November. But we are going to get 

a lot of work out of him. He knows this stuff, and he is going to 

be a good addition to the U.S. Senate. 

All right. I think that is it. It is a wrap, and with that this hearing is adjourned. Thank you. 

[Whereupon, at 4:59 p.m., the Committee was adjourned.] 

(37) 

A P P E N D I X 

Opening Statement ofCbairman Tbomas R. Carper 

"Curbing Prescription Drug Abuse in Medicare" 

June 24, 2013 

As preparedfor delivery: 

Today we will hear from several witnesses about the Medicare prescription drug program, and its 

vulnerability to waste, fraud and abuse. 

Medicare is a critical component of health care in our nation. The prescription drug program, 

also known as Medicare Part D, began in January, 2006. We are now into the seventh year, and 

the overall reviews of the program have been positive, with more than 31 million seniors 

participating. However, Congress must ensure sure that the $60 billion a year program works 

effectively and efficiently. Unfortunately, Medicare - including Part D - isn't as effective or 

efficient as it could or should be when it comes to preventing waste and fraud. 

Each year, the federal government lists the estimates of overpayments, underpayments, 

undocumented expenditures and other kinds of mistakes made by each agency. 

The total for fiscal year 2012 was more than a hundred billion dollars. Medicare has the largest 

reported share of that total at $44.3 billion. And the amount wasted in Medicare's prescription 

drug program alone is $1.6 billion. 

In addition, health care is too often the focus of criminals who wish to take advantage of the 

system. Whether the care is provided through government programs or the private sector, 

attempts to defraud the health care system are on the rise. There are estimates for Medicare 

fraud in the billions of dollars. 

We simply cannot afford to tolerate these levels of waste and fraud in our federal health care 

programs. As everyone in this room knows, we've faced record budget deficits in recent years. 

Given the debt and deficit problems our country faces, and the tough work ahead of us as we 

attempt to address those challenges, we need to focus like a laser on the avoidable, expensive, 

and frankly unacceptable issues we'll be discussing today. 

During a subcommittee hearing that I chaired in the fall of2011, the Government 

Accountability Office testified that they identified about 170,000 beneficiaries who acquired 

the same class of frequently abused drugs, primarily hydrocodone and oxycodone, from five or 

more medical practitioners at a taxpayer cost of $148 million. In two egregious examples, 

individuals received prescriptions from 87 and 58 different medical practitioners. This followed 

a similar study by the GAO in 2009 showing the same problem in Medicaid. 

This fraud technique is called 'doctor shopping.' It involves recipients going to multiple doctors 

for the same type of drug. In these cases, beneficiaries are almost always either feeding an 

addiction or seIling the drugs they don't use on the street. Drug dealers make the profit, while 

the federal government foots the bill. 
38 

But the problem of prescription drug fraud is about more than just a loss of taxpayer dollars. It's 

also about the toll drug abuse takes on people. It is of great concern that one out of seven high 

school seniors in America has abused, or is abusing, prescription drugs. In fact, more Americans 

abuse prescription drugs than the number who abuse cocaine, heroin, hallucinogens, Ecstasy, and 

inhalants, combined. 

The Department of Health and Human Services, specifically the Centers for Medicare and 

Medicaid Services, has established a set of oversight procedures to protect the Medicare 

Prescription Drug Program and its beneficiaries from fraud and waste. This is a team effort 

involving Medicare officials, law enforcement at the federal, state and local levels, the Medicare 

prescription drug plans, pharmacies and doctors, and the beneficiaries themselves. Unfortunately, 

based on today's testimony by the Health and Human Services Office ofInspector General, there 

is still a lot more work to do. 

On Thursday of last week, the inspector general released a report detailing over 700 general-care 

practitioners who had questionable Medicare Part D prescribing patterns. For example, while 

prescription drugs with a high abuse potential constitute on average only 2 percent of most 

general practitioners' prescriptions, they constituted 78 percent for one general practitioner 

identified in the report. 

This physician prescribed a year's supply of three painkillers, such as morphine and codeine, for 

just one Medicare beneficiary. Another general practitioner's prescriptions were filled at 872 

different pharmacies in 47 states, including Guam. 

Today, we will learn about an even more clear failure of oversight. The inspector general is 

reporting that Medicare is paying for prescription drugs, prescribed not be physicians or others 

authorized to prescribe drugs, but people with no authority to prescribe at all. Apparently, 

400,000 prescriptions totaling $31.6 million were prescribed by individuals 

who appear to be massage therapists, interpreters, music and art therapists, and contractors who 

perform health-care related home repairs. 

The most disturbing finding in the inspector general's report is that 29,000 of these prescriptions 

were for controlled substances, including drugs with a high potential for abuse, such as 

oxycodone. One contractor alone wrote 79 prescriptions for commonly abused pain killers. 

Obviously, these numbers and examples show clear indicators of abuse and fraud. As a 

recovering Governor, I understand the unique challenges that come along with running a major 

program like Medicare. However, we simply have to do a better job in overseeing the Medicare 

prescription drug program. 

I will continue to work with my colleagues and the Administration to ensure that programs 

across the federal government are improving management functions, monitoring results, and 

finding ways to do more with less in almost everything they do. A key part of these efforts will 

involve program managers sharpening their pencils and, in conjunction with our private sector 

partners, preventing expensive and harmful waste and fraud. We must use every tool available to 

2 
39 

make sure that our health care programs help those who need medications, rather than feed drug 

addictions or fraudulent profiteering. By working together on this latest in a series of common 

sense initiatives, we can take another important step forward in earning their trust once again. 

3 
40 

RANKING OF COMMONLY 

ABUSED DRUGS 

1 MARIJUANA 

2 PRESCRIPTION DRUGS 

3 COCAINE 

4 HALLUCINOGENS 

5 INHALANTS 

6 HEROIN 
41 

EXAMPLES OF UNAUTHORIZED PRESCRIBERS 

IDENTIFIED BY THE INSPECTOR GENERAL 

Dieticians and Nutritionists 

Audiologists 

Massage Therapists 

Athletic Trainers 

Opticians 

Dental Hygienists 

Contractors (health-care related home modifications) 

Home Health Aides 

Interpreters 

Transportation Companies 

Music or Art Therapists 

Nursing Technicians 

Veterinarians 
MEDICARE PAID FOR PRESCRIPTIONS 

Made by Individuals 

WITHOUT PRESCRIBING AUTHORITY 

417,269 Prescriptions 

29,212 Controlled Substances Prescriptions 

15,484 Prescribers 

$31.6 million Loss-to-Taxpayers 
43 

ilepnrlment of lrusure 

STATEMENT OF 

JOSEPH T. RANNAZZISI 

DEPUTY ASSISTANT ADMINISTRATOR 

OFFICE OF DIVERSION CONTROL 

DRUG ENFORCEMENT ADMINISTRATION 

BEFORE THE 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

FOR A HEARING ENTITLED 

"CURBING PRESCRIPTION DRUG ABUSE IN MEDICARE" 

PRESENTED ON 

JUNE 24, 2013 
44 

Testimony of Deputy Assistant Administrator Joseph T. Rannazzisi 

Office of Diversion Control, Drug Enforcement Administration 

before the United States Senate 

Introduction 

Committee on Homeland Security and Governmental Affairs 

Monday, June 24, 2013 

Chairman Carper, Ranking Member Coburn, and distinguished Members of the Committee on 

Homeland Security and Governmental Affairs, on behalf of Drug Enforcement Administrator 

Michele M. Leonhart and the men and women of the Drug Enforcement Administration (DEA), I 

want to thank you for the opportunity to discuss the epidemic of pharmaceutical controlled 

substance abuse and the diversion of controlled substance pharmaceuticals. 

Abuse of Controlled Substance Pharmaceuticals 

The abuse of prescription drugs continues to plague the nation at an alarming rate, crossing all age, 

gender, racial and socioeconomic boundaries. Studies show substantially high levels in the abuse 

and misuse (non-medical use) of these drugs and the adverse consequences associated with such 

actions. According to the Substance Abuse and Mental Health Services Administration's 

(SAMHSA's) 2011 National Survey on Drug Use and Health (NSDUH)-the most recent 

NSDUH-the number and percentage of persons aged 12 or older who were current (past month) 

nonmedical users of psychotherapeutic drugs in 20 II (6.1 million or 2.4 percent) were lower than 

the estimates in 2010 (7.0 million or 2.7 percent) and 2009 (7.0 million or 2.8 percent). 

Psychotherapeutic drugs include prescription-type pain relievers, tranquilizers, stimulants, or 

sedatives, but not over-the-counter substances. Although the most recent statistics reveal a slight 

downward trend, the abuse of pharmaceutical controlled substances is still alarming. 

An estimated 8.0 million people aged 12 or older (3.1 percent of the population) were current users 

of illicit drugs other than marijuana in 2011; the majority of these users (6.1 million persons, or 2.4 

percent of the population) were non-medical users of psychotherapeutic drugs. In 2011, 2.3 million 

persons aged 12 or older used psychotherapeutic drugs non-medically for the first time within the 

previous year, which averages to around 6,400 initiates per day. The number of new non-medical 

users of psychotherapeutic drugs in 2011 was similar to the 2010 estimate (2.4 million), but lower 

than the 2004 estimate (2.8 million). Of the total number of non-medical users of psychotherapeutic 

drugs in 2011, the number of new non-medical users of pain relievers (1.9 million) was lower than 

the numbers in 2002 through 2005 and in 2008 and 2009 (ranging from 2.2 million to 2.5 million). 

In 2011, the number of initiates of other psychotherapeutic drugs was 1.2 million for tranquilizers, 

670,000 for stimulants, and 159,000 for sedatives.! The non-medical use of prescription drugs is 

the second-leading category of illicit drug use among Americans 12 and older-second only to 

I Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug 

Use and Health. 
45 

marijuana use2 Among this population, the number of new initiates who used narcotic pain 

relievers is second only to the number of new initiates who used marijuana. 3 

This data is particularly disturbing because prescription opiate abuse by teens and young adults can 

lead to heroin abuse. DEA intelligence has shown that the "street" cost of prescription opiates - as 

high as $80.00 per tablet or more in the case ofOxyContin 80 mg, and $30.00 to $40.00 per tablet 

for 30 mg oxycodone single entity immediate release - makes it difficult for teens and young adults 

to purchase the drugs to continue use in support of their addiction. As a result, intelligence indicates 

that some users of prescription opiates tum to heroin, a much cheaper opiate that provides a similar 

"high" and keeps the drug seeker/abuser from experiencing painful withdrawal symptoms. This 

cycle has been confirmed by police agencies throughout the country, who are now reporting an 

increase in heroin use by teens and young adults who began their cycle of abuse with prescription 

opiates. In 2011,178,000 persons aged 12 or older used heroin for the first time within the previous 

12 months. Although this number was similar to the estimates in 2010(142,000) and 2009 

(187,000), the 2011 estimate was higher than the estimates during 2005 to 2007 (ranging from 

90,000 to 108,000 per year). A special analysis by NSDUH researchers indicates that 81 percent of 

heroin initiates in 2008-2010 had previously used pain relievers non-medically.4 Among recent 

initiates aged 12 to 49, the average age for first-time heroin use was 22.1 years, which was similar 

to the 20 I 0 estimate (21.4 years). 5 

This cycle of abuse can be traced to the mistaken belief among teens and young adults that 

prescription medications are safer than other drugs of abuse such as heroin, cocaine, marijuana, and 

methamphetamine, combined with, at least initially, easy access to prescription medications. The 

2012 Partnership Attitude Tracking Study CPA TS) noted that 43 percent of teenagers believe that 

prescription medications are "easier to obtain" than illegal drugs. 6 Because prescription 

medications are manufactured by pharmaceutical companies, prescribed by physicians and other 

medical professionals, and dispensed by pharmacists, teens and young adults often have a false 

sense of security regarding these potent and dangerous medications. In fact, according to the same 

2012 PATS, 27 percent of teens mistakenly believe that misusing or abusing prescription drugs is 

"safer" than using street drugs. 7 Other key points revealed in the 20 12 PATS are that I in 4 teens 

(24 percent) admitted to having misused or abused a prescription drug at least once in their lifetime; 

33 percent ofteens said they believe "it's okay to use prescription drugs that were not prescribed to 

them to deal with an injury, illness, or physical pains;" and 23 percent of teens said their parents 

don't care as much if they are caught using prescription drugs without a doctor's prescription, 

compared to getting caught with illegal drugs. 8 Sixteen percent of teens said they discussed the 

misuse or abuse of prescription pain relievers with their parents.9 

2 Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug 

Use and Health. 

3 Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug 

Use and Health. 

4 Gfroerer, Joe and Muhuri, Pradip. Associations between nonmedical pain reliever use and heroin initiation. 

Presentation at ONDep Interagency Meeting on Heroin. June 28, 2012. 

5 Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use 

and Health. 

6 Partnership for a Drug-Free America, 2012 Partnership Attitude Tracking Study, Full Report, Page 10. 

7 Partnership for a Drug-Free America, 2012 Partnership Attitude Tracking Study, Key Findings. 

8 Partnership for a Drug-Free America, 2012 Partnership Attitude Tracking Study, Key Findings. 

9 Partnership for a Drug-Free America, 2012 Partnership Attitude Tracking Study, Key Findings. 

2 
46 

As one would expect, this abuse leads to increased diversion, and, in tum, increased enforcement 

activity. The National Forensic Laboratory Information System (NFLIS) collects results of drug 

chemistry analyses conducted by Federal, state, and local forensic laboratories across the 

country. As such, NFLIS can provide detailed analytical results of drugs seized by law 

enforcement, including trends in the diversion of pharmaceutical controlled substances into illegal 

markets. As of June 14,2013,47 state laboratory systems, 94 local laboratory systems, and one 

territorial laboratory system were participating in NFLIS. In 20 I 0, approximately 1.7 million drug 

analysis records were reported to NFLIS. The increase in opiate pain medication analyses 

conducted by NFLIS-reporting laboratories from 200 I to 20 lOis staggering: 322 percent for 

oxycodone; 240 percent for hydrocodone; and 253 percent for morphine. 

Drug abuse is a problem that cannot be addressed through law enforcement action alone. We will 

never be able to "arrest our way" out of this problem. The Office of National Drug Control Policy's 

20 II Prescription Drug Abuse Prevention Plan, a mUlti-pronged approach that includes education, 

monitoring, proper medication disposal, and enforcement is a science-based and practical way to 

address this national epidemic. One role of DE A, in addition to enforcing the Controlled 

Substances Act (CSA), is to educate the registrant population-including health care providers-on 

their obligations under the CSA, as well as to educate parents, community leaders and law 

enforcement personnel regarding diversion trends, the scope of the problem, and how to best 

address prescription drug diversion in communities throughout the United States. 

One of the factors that contribute to the abuse of pharmaceutical controlled substances is the 

perception by some members of the public that it is safer to abuse prescription substances than to 

abuse illicit substances. Additionally, black-market sales for prescription controlled substances are 

typically at five to ten times the retail value. Profits generated from these street sales provide a 

strong incentive for continued diversion. Another factor that contributes to the increase of 

prescription drug diversion is the availability of these drugs in the household. In many cases, 

dispensed controlled substances remain in household medicine cabinets well after medication 

therapy has been completed, thus providing easy access to non-medical users for abuse, accidental 

ingestion, or illegal distribution for profit. Accidental ingestion of medication, including a 

controlled substance, by the elderly and children, is more likely when the household medicine 

cabinet contains unused medications that are no longer needed for treatment. The medicine cabinet 

also provides ready access to persons, especially teenagers, who seek to abuse medications. The 

20 12 PATS noted that 56 percent ofteens indicated that it's easy to get prescription drugs from their 

parent's medicine cabinet and, in fact, 49 percent of parents say "anyone can access their medicine 

cabinet.,,10 Furthermore, the 2011 NSDUH indicates that 71 percent of individuals in 2010-2011 

who used pain relievers nonmedically in the past year obtained them from a friend or relative. 11 

DEA has responded to this problem by coordinating, every six months, National Prescription Drug 

Take-Back events with our Federal, state, local, and tribal law enforcement partners. Since 

September 2010, DEA has held six National Prescription Drug Take-Back Days, resulting in the 

collection of approximately 2.8 million pounds (1,409 tons) of unwanted prescription drugs. 

Removing household medication that is unwanted or no longer needed is a key component to 

limiting the availability of and access to these drugs by children and drug seekers for non-medical 

purposes. DEA is fully engaged in ensuring proper disposal of controlled substances and is 

10 Partnership for a Drug-Free America, 2012 Partnership Attitude Tracking StUdy, Key Findings. 

11 Substance Abuse and Mental Health Services Administration. Results from the 2011 National Survey on Drug 

Use and Health. 

3 
47 

currently finalizing regulations implementing the Secure and Responsible Drug Disposal Act of 

2010, which authorizes additional ways for Americans to dispose of their unwanted or expired 

controlled substance medications in a secure and responsible manner. 

Means by Which Pharmaceutical Controlled Substances Are Diverted 

Understanding the means by which controlled substances are diverted is critical in determining 

appropriate regulatory controls. Diversion of pharmaceutical controlled substances can occur in 

a number of ways, including, but not limited to, the following: 

• Prescription pads are stolen from practitioners' offices by patients. staff, or others, and 

illegitimate prescriptions are written and forged. 

• Legitimate prescriptions are altered to obtain additional amounts oflegitimately 

prescribed controlled substances. 

• Drug-seeking patients may falsify symptoms or obtain multiple prescriptions from different 

practitioners for their own use or for resale. In some cases, organized groups visit 

practitioners with fake symptoms to obtain prescriptions, which are filled and resold. Some 

patients resell their legitimately obtained drugs to earn extra money. 

• Prescription pads containing legitimate practitioner information (e.g., name, address, DEA 

registration number) are printed with a different call-back number that is answered by an 

accomplice to verify the prescription. 

• Computers and scanning or copying equipment are used to create prescriptions for nonexistent practitioners or to copy legitimate practitioners' prescriptions. 

• Pharmacies and other locations where pharmaceutical controlled substances are stored are 

robbed or burglarized. 

Diversion from within the practitioner's practice or pharmacy may also occur, such as in the 

following situations: 

• Prescriptions are written for other than a legitimate medical purpose. 

• Pharmaceutical controlled substances are stolen from pharmacies by pharmacy personnel. 

Legitimately dispensed prescriptions may be altered to make the thefts less detectable. 

• Pharmacists are not exercising their coordinating responsibility to ensure that prescriptions 

are valid. 

Recent Schemes to Divert Controlled Substances 

Over the past several years, DEA Diversion Investigators and Special Agents have uncovered two 

types of illegal schemes used to divert powerful and addictive controlled substance pharmaceuticals. 

Florida was the epicenter of many illegal operations whereby hundreds of millions of dosage units 

of controlled substances were diverted into the illicit marketplace across the United States. Between 

2005 and 2009, the diversion of millions of dosage units of Schedule III hydrocodone products was 

4 
48 

facilitated by rogue internet pharmacies and unscrupulous prescribers who provided prescriptions to 

drug seekers utilizing these sites. 

The Ryan Haight Online Pharmacy Consumer Protection Act that took effect in April 2009 

responded to the explosion of domestic rogue internet phannacy diversion. This law, combined 

with intensified law enforcement and regulatory actions, virtually eliminated domestic-based rogue 

internet pharmacies that were involved in internet controlled substance distribution. Internet 

traffickers have adapted to the law, for example by selling legend drugs and Fioricet (containing 

butalbital, a Schedule III controlled drug), which is exempt from administrative regulations but not 

criminal sanctions under the CSA. 

As the number of domestic, internet-based pharmacies began to decline in 2008, law enforcement 

observed a significant rise in the number of rogue pain clinics, particularly in Florida. Instead of 

hydrocodone, the practitioners in these clinics dispensed millions of dosage units of oxycodone, a 

Schedule II controlled substance that is just as dangerous as hydrocodone when taken for a nonmedical use. There was a sharp increase in pain clinics located in the tri-county area of South 

Florida (comprised ofBroward, Miami-Dade, and Palm Beach Counties) in 2009. According to 

data provided by the State of Florida, by 2010, Broward County alone was home to approximately 

142 rogue pain clinics. Federal, state and local law enforcement investigations identified thousands 

of drug seekers that routinely traveled to Florida-based rogue pain clinics to obtain pharmaceutical 

controlled and non-controlled substances, such as oxycodone, hydromorphone, methadone, 

tramadol, alprazolam, clonazepam, and carisoprodol. They then would travel back to their home 

states and illegally distribute the drugs that ultimately flooded the illicit market in states along the 

entire East Coast and the Midwest. 

In response to this problem, state legislation in Florida was implemented to restrict a physician's 

ability to dispense oxycodonc and other controlled substances from a pain clinic. However, 

dispensing controlled substances from these clinics was a huge source of income for clinic owners. 

Some clinic owners moved operations out of Florida to avoid increased law enforcement and 

regulatory pressure and the new legislation. Federal, state, and local law enforcement agencies have 

tracked the expansion of these clinics to other states, including Georgia, Tennessee, Ohio, Missouri, 

Texas, California, and Pennsylvania. Other rogue pain clinic owners and practitioners adapted to 

the new laws by issuing illegitimate prescriptions for oxycodone and other controlled substances 

rather than dispensing directly to the "customer." DEA and other law enforcement agencies saw an 

immediate and significant increase in the volume of oxycodone dispensed from various ph~nnacies 

across the State of Florida. 

Seeing their profits going to dispensing pharmacies across the State, clinic owners began purchasing 

pharmacies and locating them at or near the pain clinics. The purchase of pharmacies is part of the 

scheme by rogue pain clinic owners to circumvent Florida laws: if a pain clinic cannot lawfully 

dispense drugs directly to a "customer," then the pain clinic will issue illegitimate prescriptions to 

"customers," and the pain clinic pharmacy will dispense drugs based on those illegitimate 

prescriptions. As a result of this scheme, there was a sharp increase in the number of new pharmacy 

registration applications in the State of Florida. The rise in the number of new pharmacy 

applications in Florida lead DEA to initiate on-site investigations of all pharmacy applications in 

Florida,12 rather than rely upon state licensure to ensure that the applicants have the requisite skill 

12 On-site investigations of registrant applicants are conducted by DEA pursuant to its authority under 21 U.S.c. 

822(1) and 21 eFR 1301.31. 

5 
49 

and experience to safely and responsibly dispense controlled substances, sufficient knowledge of 

applicable federal law and regulations, and that the applicants intend to comply with Federal laws 

and regulations. 

Further investigation of pharmacy applicants revealed "straw purchases" of pharmacies that had ties 

to established rogue pain clinics. During the on-site investigations, DEA personnel interviewed 

numerous applicants with backgrounds such as drywall installer, truck driver, bartender, lawn 

service owner, and spouse of a pain clinic owner. Many ofthe applicants had little or no experience 

with pharmacy operations. To date, this initiative has conducted five deployments to Florida. As a 

result, 132 retail pharmacies and one distributor have withdrawn their applications. The majority of 

these withdrawals, including the distributor application, were located in South Florida. As a result 

of this and other initiatives in Florida, 154 existing retail pharmacies have surrendered their 

registrations (again, the majority of which were in South Florida). Preventing these pharmacies 

from conducting business undoubtedly prevented millions of dosage units of controlled substances 

from entering the illicit market and closed an avenue of distribution and source of income for the 

rogue pain clinics. This initiative is on-going and has been expanded to other states where DEA has 

seen an unexplained increase in pharmacy applications. 

DEA-registered pharmacies are generally supplied by DEA-registered wholesale distributors. 

Rogue pain clinics, pharmacies that fill illegitimate prescriptions for pain clinic "patients," and the 

wholesale distributors who supply these pharmacies have caused, and continue to cause, millions of 

dosage units of oxycodone and other controlled substances to be diverted. Consequently, the 

registrants involved-practitioners, pharmacies, and wholesale distributors that do not comply with 

the CSA and its implementing regulations-are allowing millions of dosage units of controlled 

substances to pour into the illicit market, posing an imminent danger to the public health and safety. 

The damage to society is evident from the number of pharmaceutical overdose deaths reported 

recently by the Centers for Disease Control (CDC). CDC analysis revealed that 38,329 people died 

from a drug overdose in the United States in 2010. Nearly 60 percent of the drug overdose deaths 

(22,134) involved pharmaceutical drugs. Opioid analgesics, such as oxycodone, hydrocodone, and 

methadone, were involved in about 3 of every 4 pharmaceutical overdose deaths (16,651), 

confirming the predominant role opioid analgesics play in drug overdose deaths. 13 

Registration and Information Sharing 

The level of control mandated by Congress for pharmaceutical controlled substances far exceeds 

that for other prescription drugs. This level of control is commensurate with the potential for 

physical and psychological dependence and abuse properties associated with controlled substances 

and is necessary to help prevent abuse and diversion ofthese substances. 

One of the most effective tools to ensure legitimate use of pharmaceutical controlled substances is 

the registration requirement. The following individuals and entities are required to be registered 

with DEA: any business that imports or exports a controlled substance, or that manufactures or 

distributes a controlled substance; pharmacies that dispense controlled substances; practitioners that 

prescribe, administer, or dispense controlled substances; and any person that conducts research or 

chemical analysis with a controlled substance. Currently, there are more than 1.4 million registrants 

registered with DEA, and the vast majority are practitioners (i.e., registered medical professionals 

13 Centers for Disease Control and Prevention, Press Release "Opioids drive continued increase in drug overdose 

deaths." (Feb. 20, 2013). 

6 
50 

who prescribe, administer, or dispense pharmaceutical controlled substances). Once registered, 

each individual or business is issued a unique DEA registration number. DEA maintains over 2 

million registration records in a database that includes historical and current regulatory action(s) 

taken against a registrant. 

DEA provides an electronic means by which registrants can check the validity of another 

registrant's DEA registration number free of charge. DEA also provides access to state agencies 

that have a responsibility to investigate health care fraud. DEA provides daily access to the 

registrant database to 41 states, Guam, and D.C., which have requested the data. DEA provides this 

data to agencies such as the New York State Medicaid Inspector General's Office; the Illinois Office 

of Inspector General Health and Family Services the Illinois Department of Human Services Bureau 

of Pharmacy and Clinical Support Services; the North Carolina Medical Board; and the Texas 

Department of Public Safety, Controlled Substances Registration section. Additionally, DEA 

provides a listing of current DEA registration numbers to the National Technical Information 

Service (NTIS), an agency of the U.S. Department of Commerce, on a weekly basis. NTIS collects 

and disseminates technical information produced by and for Federal agencies. It operates on a selfsustaining basis and makes this information widely available to those who need it on a subscription 

basis at no cost to the Treasury. DEA currently receives the Social Security Death Master List, and 

cross-checks that information with DEA registration records to better reconcile these two databases 

and thereby curb potential avenues of health care fraud. 

The CSA and DEA Regulations Pertaining to Prescriptions for Controlled Substances 

In enacting the CSA, Congress sought to control the diversion of pharmaceutical controlled 

substances into illicit markets by establishing a closed system of distribution for controlled 

substances. The CSA requires that a prescription for a controlled substance may be issued only by a 

practitioner who is registered with DEA, or exempt from registration, and who is also authorized to 

prescribe controlled substances by the state in which they are prescribing. The CSA and its 

implementing regulations help maintain the integrity of this closed system of distribution by 

requiring registrants to adhere to specified security, recordkeeping, and reporting requirements, as 

well as controlling and limiting legitimate transfers of controlled substances by and between 

specified registrants. When DEA registrants adhere to the CSA and its implementing regulations, 

diversion of pharmaceutical controlled substances from the closed system of distribution is 

prevented. 

The closed system is specifically designed to ensure that there are multiple ways of identifying and 

preventing diversion through active participation by registrants within the drug delivery chain as 

well as the registrants within the health care delivery system. All registrants must adhere to specific 

security, recordkeeping, monitoring, and reporting requirements that are designed to identifY or 

prevent diversion. Adherence to these requirements at every level of the delivery and supply chain 

will reduce the opportunities for diversion. 

Practitioners, such as prescribers and pharmacists, must adhere to additional requirements when 

prescribing or dispensing controlled substances. For example, an individual practitioner such as a 

physician, dentist, veterinarian, or mid-level practitioner may only dispense or prescribe a controlled 

substance for a legitimate medical purpose while acting in the usual course of professional practice. 

21 CFR §1306.04(a); United States v. Moore, 423 US 122 (1975). While the vast majority of 

practitioners act in accordance with the law, requirements such as this are disregarded at rogue pain 

7 
51 

clinics operating throughout the United States. Rather than providing medical care, they utilize the 

fayade of medical care as a front for illegal controlled substance distribution activities. The 

"physicians" that operate in rogue pain clinics are feeding the addiction of drug seekers. These 

clinics have minimal physician-patient interaction and generally provide the medication requested 

by the patient (patient-directed prescribing) without question. There is no attempt to determine the 

underlying cause of pain and the standard accepted medical practice is disregarded. Most of the 

practitioners that write prescriptions in these facilities are committing criminal and civil violations 

of the CSA. If the practitioners in these clinics were to abide by the requirement to issue a 

prescription only for a legitimate medical purpose and in the usual course of professional practice, 

drug seekers would not have the opportunity to feed their addiction or to distribute pharmaceutical 

controlled substances into the illicit market. 

A legitimate prescription may be filled only by a pharmacist acting in the usual course of 

professional practice who is employed in a DEA-registered pharmacy. Except under limited 

circumstances, a pharmacist may dispense a schedule II controlled substance only upon receipt of a 

valid electronic prescription or an original written prescription manually signed by the practitioner. 

A pharmacist may dispense a schedule III or IV controlled substance only pursuant to a legitimate 

oral, written, or electronic prescription from an individual practitioner. The elements of a 

prescription that identify the practitioner (i.e., the practitioner's name, address, DEA 

registration number, and signature) also serve to enable a pharmacy to authenticate the 

prescription. If a pharmacy is unfamiliar with the practitioner identified on the prescription, it 

can use the registration number to verify the identity and prescriptive authority of the 

practitioner. 

Ultimately, the last line of defense against diversion is the pharmacist that receives the prescription 

for medication dispensing. The pharmacist is obligated to ensure that a prescription for a controlled 

substance is legitimate before dispensing the medication to the patient. "The responsibility for the 

proper prescribing and dispensing of controlled substances is upon the prescribing practitioner, but a 

corresponding responsibility rests with the pharmacist who fills the prescription. An order 

purporting to be a prescription issued not in the usual course of professional treatment ... is not a 

prescription ... and the person knowingly filling such a purported prescription ... shall be subject 

to the penalties provided for violations ofthe provisions of law relating to controlled substances." 

21 CFR §1306.04(a). The pharmacist is the "drug expert" in the healthcare delivery system and is 

well equipped to review a prescription to determine ifit is legitimate. If more pharmacists 

questioned the validity of prescriptions issued by rogue pain clinic physicians and refused to fill the 

prescriptions based upon their professional judgment, diversion would be significantly decreased. 

The exercise of their "corresponding responsibility," in many instances, is an opportunity for 

pharmacists to save lives. 

DEA regulations require registered pharmacies to maintain records of dispensing activities for 

two years from the date of dispensing of the controlled substance. However, some states 

require that these records be maintained for longer periods of time. These records must be 

made available for inspection and copying by authorized employees ofDEA. This system of 

records is unique in that the prescribing practitioner creates the prescription, but the dispensing 

pharmacy retains the prescription as a reeord of dispensing. DEA does not have authority to 

require pharmacies to report their controlled substance dispensing activities to DEA. However, 

DEA does have an administrative authority to access these records stemming from the 

authority to inspect registered premises. 

8 
52 

Prescription Drug Monitoring Programs 

Prescription drug monitoring programs (PDMPs) are typically electronic database systems 

used by practitioners, pharmacists, medical and pharmacy boards, and law enforcement. 

These programs are established through state legislation and are tailored to the specific needs 

of a particular state. DEA strongly supports PDMP programs and encourages the use of these 

programs by medical professionals in detecting and preventing doctor shopping and other 

forms of diversion. Currently, 46 states have an operational PDMP; 3 more states have enacted 

PDMP legislation, but do not have operations programs; and 1 state (Missouri) and the District 

of Columbia do not have legislation. Additionally, DEA makes its registrant database available 

to any state, without a fee, for use in their PDMP or other state agency charged with 

investigating health care fraud or controlled substance diversion. These programs, however, 

are only as good as the data that is in each system and the willingness of practitioners and 

pharmacists to use such systems on a consistent basis. 

Medicare and Medicaid Fraud 

Federal investigations of health care fraud are conducted pursuant to the authority of Title 18 U.S.c. 

§§ 287 and 1001, 18 U.S.C. § 1347, 18 U.S.c. §1518 and Title 42 U.S.C. § 1320a-7b. State 

agencies also have authority to investigate Medicaid fraud within their jurisdictions. While these 

violations are outside DEA's jurisdiction, there are occasions when, while investigating violations 

of the Controlled Substances Act, DEA agents and investigators uncover violations involving health 

care fraud. This information is shared with investigators from the Department of Health and Human 

Services (HHS), the Federal Bureau ofInvestigation (FBI), and other investigative agencies with 

relevant Federal or state authorities. 

The importance of these cooperative and information sharing relationships are reflected in the fact 

that HHS Office of the Inspector General, the FBI, and others have investigators assigned or are 

working on an ad-hoc basis with some of our Tactical Diversion Squads. This expertise and contact 

facilitates information sharing between all of the involved agencies, and allows investigators to 

easily draw upon each other's expertise when conducting an investigation. 

The Drug Enforcement Administration Response to the Prescription Drug Abuse Crisis 

Just as illicit drug traffickers and organizations adapt to law enforcement methods, pharmaceutical 

traffickers adapt to and circumvent laws that attempt to stop the flow of controlled substance 

pharmaceuticals into the illicit market. As such, law enforcement efforts to prevent, detect, and 

reduce the diversion of controlled substance pharmaceuticals continue to evolve. DEA has taken 

action on several fronts over the past few years to help reduce this growing problem. 

Restructuring 

In October 2008, the then-Acting Administrator authorized a two-pronged reorganization of the 

Diversion Control Program. The first prong involved a substantial expansion in the number of 

Tactical Diversion Squads (TDSs) and their deployment throughout the United States. This 

approach provided a significant increase in the number of Special Agents and Task Force Officers 

who possess the requisite law enforcement authorities needed when conducting criminal 

investigations, i.e., the ability to conduct surveillance, make undercover purchases, make arrests, 

and execute search warrants. The second prong of the reorganization plan called for a renewed 

9 
53 

focus on DEA's regulatory oversight of more than 1.4 million DEA registrants. With more 

Diversion Investigators available to concentrate on the regulatory aspects of the Diversion Control 

Program, DEA increased the frequency of compliance inspections of specific registrant categories 

such as manufacturers (including bulk manufacturers); distributors; importers; exporters; narcotic 

treatment programs; practitioners waived under the Drug Addiction Treatment Act to prescribe 

certain controlled substances to treat opioid addiction and dependence without obtaining a separate 

registration to do so; researchers; and chemical handlers. This renewed focus on oversight has 

enabled DEA to take a more proactive approach to educate registrants and ensure that DEA 

registrants understand and comply with the Controlled Substances Act and its implementing 

regulations. 

Expansion a/Tactical Diversion Squad~ 

Tactical Diversion Squads (IDS) investigate suspected violations of the CSA and other Federal and 

state statutes pertaining to the diversion of controlled substance pharmaceuticals and listed 

chemicals. These unique groups combine the skill sets of Special Agents, Diversion Investigators, 

and a variety of state and local law enforcement agencies. They are dedicated solely towards 

investigating, disrupting, and dismantling those individuals or organizations involved in diversion 

schemes (e.g., "doctor shopping," prescription forgery rings, and practitioners or pharmacists who 

divert controlled substance pharmaceuticals). 

As of June 14,2013,66 TDS groups have been approved throughout the United States, of which 51 

are operational. With the expansion ofTDS groups across the U.S., the number of diversion-related 

criminal and administrative cases has increased significantly. For example, between fiscal year 

(FY) 2008 and FY 2012, regulatory inspections increased from 1,192 to 4,675 (a 392% increase). 

Between FY 2008 and FY 2011, administrative actions, including Orders To Show Cause and 

Immediate Suspension Orders, increased from 70 to 131 (a 87% increase). An Order To Show 

Cause, which commences administrative action against a registrant, is an order from DEA that 

provides notice to a registrant that the registrant may show cause, at an administrative hearing or 

through submission of documentary evidence, as to why the DEA should not revoke their 

registration or deny their application for a DEA registration on the basis of any of the enumerated 

statutory factors. An Immediate Suspension Order is an administrative action in which the DEA 

Administrator simultaneously suspends the registrant's DEA registration with the commencement 

of Order to Show Cause proceedings because their continued registration pending the administrative 

proceeding would pose an imminent danger to the public health or safety. 

Between FY 2008 and FY 2013 as of June 13,2013, these TDS groups have also increased the 

number of diversion-related Priority Target Organization (PTO) investigations from 243 to 595 (a 

141 % increase). PTO investigations focus on those criminal organizations or groups that 

significantly impact areas of the country. On October 1, 2011, DEA began tracking non-criminal 

PTO investigations, which encompass regulatory, civil, and administrative investigations. Since 

then, there have been 75 designated non-criminal PTO investigations. 

The restructuring of the Diversion Control Program has allowed investigative efforts to focus on 

specific problem areas. For example, DEA, working with its state and local partners, put forth a 

substantial investigative effort towards rogue clinics, dubbed Operation Pill Nation 1. This 

operation involved the mobilization of eleven TDSs from across the United States to marshal with 

the Miami TDS and other state and local agencies in a concerted effort to attack and dismantle the 

hundreds of rogue pain clinics that continued to plague South Florida. On February 23,2011, DEA, 

10 
54 

as part of Operation Pill Nation I, conducted a coordinated effort with more than 500 state and local 

law enforcement officers in a massive takedown. As of June 14,2013, Operation Pill Nation I 

resulted in 47 arrests, including 27 doctors; the issuance of 34 Immediate Suspension Orders against 

63 DEA registrations; 92 DEA registrations being surrendered for cause; and the seizure of more 

than $18.9 million in assets. 

DEA conducted a similar operation in the central Florida area, dubbed Operation Pill Nation 11. As 

ofJune 6, 2013, Operation Pill Nation II has resulted in 58 arrests, including 9 doctors and 4 

pharmacists; the issuance of 4 Immediate Suspension Orders; 7 DEA registrations being 

surrendered for cause; and the seizure of approximately $311,995 in assets. 

Renewed Oversight 

DEA uses its regulatory authority to ensure that DEA registrants comply with all aspects of the CSA 

and its implementing regulations, particularly maintaining effective controls against diversion, and 

monitoring for and reporting suspicious orders. One way DEA attempts to accomplish this is 

through our Distributor Initiative Program. This program was implemented in late 2005 and is 

designed to educate wholesale distributors who were supplying controlled substances to rogue 

Internet pharmacies and, more recently, to rogue pain clinics and rogue pharmacies. The goal of 

this educational program is to increase distributor awareness and vigilance so that they cut off the 

source of supply to these and other schemes, As stated above, wholesale distributors are required to 

design and operate a system that will detect suspicious orders and report those suspicious orders to 

DEA. Through the Distributor Initiative Program, DEA educates distributors about their obligations 

under the CSA, as well as provides registrants with current trends and "red flags" that might 

indicate that an order is suspicious, such as the type ofdrug(s) ordered, orders of unusual size, 

orders that deviate from a normal pattern, frequency of orders, breadth and type of products ordered, 

and the location of the customer. 

DEA vigorously pursues criminal, administrative, and civil actions against registrants who fail to 

comply with all aspect of the CSA and its implementing regulations as required. DEA has 

identified various distributors who failed to adhere to their regulatory responsibilities to maintain 

effective controls against diversion, resulting in administrative action and referral for civil action. 

These investigations resulted in record-breaking civil penalties ($13.25 million against McKesson 

Drug Corporation in April 2008 and $34 million against Cardinal Health in October 2008). More 

recent examples include, but are not limited to, actions against wholesale distributors such as 

Harvard Drugs, Keysource, and Sunrise. 

In February 2012, the DEA Administrator again used her authority under the CSA to immediately 

suspend the registrations of Cardinal Health's Lakeland, Florida, facility and two Sanford, Floridabased CVS pharmacies (stores 219 and 5195) after making a determination that the continued 

operation of these facilities (with respect to controlled substances), while pending administrative 

proceedings to revoke their registrations posed an imminent danger to the public health or safety. A 

Memorandum of Agreement has been reached between DEA and Cardinal Health regarding their 

conduct, which includes a suspension of their Lakeland facility registration for a period of two 

years. On August 31, 2012, the DEA Administrator issued a Final Order revoking the registrations 

of both of the CVS pharmacies. 

On March 29, 2013, as a result of an eight-year investigation of illegal Internet phannacies, United 

Parcel Service, Inc. (UPS) agreed to forfeit $40 million, which was alleged to be the profits earned 

II 
55 

from conducting business with illegal Internet pharmacies, to the U.S. Government and entered into 

a non-prosecution agreement. This agreement requires the world's largest package delivery 

company to implement a comprehensive compliance program prohibiting illegal Internet 

pharmacies from using their services. 

On June 11,2013, Walgreens Corporation, the nation's largest drug store chain, agreed to pay $80 

million in civil penalties, resolving DEA's administrative actions and a civil penalty investigation 

by the United States Attorney's Office regarding the Jupiter Distribution Center and six retail 

pharmacies in Florida. The settlement, the largest in DEA history, resolved the allegations that 

Walgreens committed an unprecedented number of record-keeping and dispensing violations under 

the Controlled Substances Act. The Settlement and Memorandum of Agreement also includes the 

suspension of the Jupiter Distribution Center registration until September 14,2014, and the 

registrations of the six pharmacies until May 26, 2014. 

Education 

DEA, along with state regulatory and law enforcement officials, and in conjunction with the 

National Association of Boards of Pharmacy, hosts Pharmacy Diversion Awareness Conferences 

(PDACs) throughout the country; to date, 16 separate PDACs have been held in 8 states. Each oneday conference is held on a Saturday or a Sunday for the convenience of the pharmacy community. 

The conference is designed to address the growing problem of diversion of pharmaceutical 

controlled substances at the retail level. The conference addresses pharmacy robberies and thefts, 

forged prescriptions, doctor shoppers, and illegitimate prescriptions from rogue practitioners. The 

objective of this conference is to educate pharmacists, pharmacy technicians, and pharmacy loss 

prevention personnel on methods to prevent and respond to potential diversion activity. In addition, 

since FY 2012, the Office of Diversion Control has separately conducted more than 100 

presentations to the public, educators, community-based organizations, registrants, and their 

professional organizations, industry organizations, and law enforcement agencies regarding the 

diversion and abuse of pharmaceutical controlled substances. 

Conclusion 

Minimizing the availability of pharmaceutical controlled substances to non-medical users and 

maintaining the integrity of the closed-system of distribution are priorities for the Drug Enforcement 

Administration. As such, DEA will continue to work in a cooperative effort with other Federal, 

state, and local officials, law enforcement, professional organizations, and community groups to 

address this epidemic. 

12 
56 

STATEMlENT:QF 

JONATHAN BLUM 

ACTING PRINCIPAL DEPUTY ADMINISTRATOR AND DIRECrOR, 

CENTER FOR MEDiCARE 

CENTERS FOR MEDICARE & MEDICAID SERVICES 

ON 

CURBING PRESCRIPTION DRl!IGAllUSEIN 

MEDICARE 

BE.FORETHE 

U.S. SENA:TECOM1\UTTEEON 

HOMELAND SECURITY ANnh()\rl£RN~~NTALAFFAIRS 

JUNE 24, 2013 
57 

Statement of Jonathan Blum on 

Curbing Prescription Drug Abuse in Medicare 

U.S. Senate Committee on Homeland Security and Government Affairs 

June 24, 2013 

Chainnan Carper, Ranking Member Coburn, and members of the Committee, thank you for 

inviting me to discuss the Centers for Medicare & Medicaid Services' (CMS) work to improve 

the Medicare Prescription Drug Program, also known as Medicare Part D, to ensure that all 

Medicare beneficiaries are receiving the medicines they need while also reducing and preventing 

prescription drug abuse. 

The Medicare Part D prescription drug benefit program has been very successful by several 

measures. In its eight years of operation, Part D has made medicines more available and 

affordable for Medicare beneficiaries, leading to improvements in access to prescription drugs, 

better health outcomes, and more beneficiary satisfaction with their Medicare coverage. In 

addition, the drug benefit is helping beneficiaries avoid the need for other services that would 

otherwise be covered under Medicare Parts A and B; the Congressional Budget Office (CBO) 

recently estimated that a one percent increase in the number of prescriptions filled by 

beneficiaries causes Medicare's overall spending on medical services to fall by roughly one-fifth 

of one percent. I 

The Medicare Part D program provides outpatient prescription drug benefits to about 37 million 

Medicare beneficiaries2 through a wide range of plan choices, with an average of 31 plans per 

regionl competing to provide drug benefits to Medicare beneficiaries at the average monthly 

premium of about $30. 4 According to surveys, 95 percent of Part D enrollees are satisfied with 

their drug coverage and confident that the level of coverage meets their needs. 5 

I http://www.cbo.govlsitesldefaultifileslcbofileslattachments/43741-MedicaIOffsets-l J -29-12.pdf. 

2 MedPAC. "Status Report on Part D." March 1,2013. http://www.medpac.govlchaptersIMarJ3 ChI5.pdf. 

3 201 3 Prescription Drug Plan Landscape available at: http://www,cms.gov/Medicare/Prescription-DmgCoverageIPrescriptionDrugCovGeniniindex.html. 

4 http://www.cms.gov/Medicare/HealthPlansiM edicareAdvtgSpecRateStats/downioadsIPartDandMABenchmarks2013 .pdf. 

5 MedPAC. "Status Report on Part D." March 1,2013. http://www.medpac.gov/chaptersIMarl3 ChI5.pdf. 
58 

Meanwhile, the overall costs for the Part D program have risen more slowly than originally 

projected. According to CBO's data, Part D is on track to cost 45 percent less than projected for 

the initiaI2004-to-2013 forecast period,6 and as we announced earlier this year, Part D's per 

capita costs will only rise 1.83 percent for 2013 - the lowest growth rate in the history of the 

program. 7 Additionally, the deductible and out-of-pocket limit for Part D will be lower in 2014 

than in 2013, and beneficiary costs will be further reduced as coverage in the prescription drug 

coverage gap, or "donut hole," continues to expand in 2014. To date, 6.3 million beneficiaries 

have saved over $6.1 billion on prescription drugs through the Affordable Care Act's discounts, 

rebates, and additional coverage. 8 

While beneficiaries are saving money on prescription drugs, the quality of Part D plans is 

improving. The average star rating among standalone Part D sponsors, weighted by enrollment, 

in 20l 3 is 3.3 stars out of five, compared with 2.96 for 20l 2. 9 These ratings are based on quality 

measures including patient safety and appropriate medication usc metrics. Sponsors have 

incorporated the Medication Therapy Management Programs into their plans' benefit structures 

to ensure optimum therapeutic outcomes through improved medication use and a reduced risk of 

adverse outcomes. 

While the Part D program is strong, CMS knows it must continually improve the program and 

address vulnerabilities. CMS appreciates the thoughtful work of this CommitteelO and the 

Department of Health & Human Services (HHS) Office of the Inspector General (OlG) II that 

highlights the potential for fraud, waste, and abuse in Part D. We agree that CMS can do more to 

reduce fraud and abuse in order to ensure that beneficiaries receive high-quality, appropriate 

care, while also making sure that we spend every federal dollar as wisely as possible. 

6 http://www.ebo.gov/5ites/defaultlfiles/ebofile5/attaehment5/44205 Medicare O.pdf 

7 Advance Notice of Methodological Changes for Calendar Year (CY) 2014 for Medicare Advantage (MA) 

Capitation Rates, Part C and Part D Payment Policies and 2014 Call Letter. 

http://www.cms.gov/MedicarelPre5cription-Drug-Coverage/PrescriptionDrugCovContraJDownloads/RateNotice.pdf 

8 http://www.hhs.gov/news/press/2013pres/03/20I30321 a.html 

9 MedPAC. "Status Report on Part D." March 1,2013. http://www.medpae.gov/ehapterslMar13 ChIS.pdf 

10 http://www.hsgae.5enate.gov/subcommittees/federal-finaneial-Inanagementlhearings/costs-of~prescription-drugabuse-in-the-medicare-part-d-program 

II HHS OIG has a large body of work examining Part D billing including: OEI-02-09-00603, OEI-02-09-00608, 

OEI-02-09-00I40, OEI-03-11-0031O, OEI-07-09-001S0, OEl-07-10-06004 

2 
59 

As the program matures, CMS is broadening its initial focus of ensuring beneficiaries have 

access to prescribed drugs to also ensure that Part D sponsors implement effective safeguards to 

prevent fraud and drug abuse, and provide coverage for drug therapies that meet standards for 

safety and efficacy. Based on the lessons learned from activities in fee-for-service Medicare and 

input from this Committee, the HHS orG, and the Government Accountability Office (GAO), 

we have enhanced our data analyses and improved coordination with our law enforcement 

partners to get a more comprehensive view of activities in the Part D program. 

Prescription drug abuse is the Nation's fastest-growing drug problem, and the Centers for 

Disease Control and Prevention (CDC) has classified prescription drug overdose as an 

epidemic. 12 In 2010, more than 100 people died from drug overdoses every day in the United 

States,IJ and drug overdose death rates have more than tripled since 1990. 14 Between 1997 and 

2008, the rate of hospital admissions for conditions related to prescription medication 

interactions and illicit drug use rose by 96 percent among people ages 65 and 84, and for people 

85 and older, admissions grew 87 percent. 15 

In response to this growth in prescription drug misuse and abuse, the Administration released its 

"Prescription Drug Abuse Prevention Plan" in 2011. 16 This plan includes four 

pillars: education, monitoring, proper disposal, and enforcement. National survey data indicate 

that the number of people in the United States currently abusing prescription drugs decreased 

from 7 million in 2010 to 6.1 million in 2011,17 a promising trend. 

12 Paulozzi, L. et al. (2012). CDC Grand Rounds: Prescription Drug Overdoses-a U.S. Epidemic. Morbidity and 

Mortality Weekly Report, 61 (01):10-13, January 13. 

"CDClWonder, extracted February II, 2013, showed 38,329 deaths in 2010. 

14 http://www.cdc.goy/homcandrecreationalsafety/rxbrief/. 

" Based on analysis by the Substance Abuse and Mental Health Services Administration, Center for Behavioral 

Health Statistic and Quality. http://www.samhsa.gov/grants/201Ilsm 11 009.aspx#f4 

16 EpidemiC: Responding to America's Prescription Drug Abuse Crisis. Executive Office of the President of the 

United States. 20 II. http://www. whitehouse.gov/sitesldefault/files/ondcplissues-content/prescriptiondJUgs/rx abuse plan O.pdf. 

17 Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings. Substance Abuse and 

Mental Health Services Administration, NSDUH Series HAS, HHS Publication No. (SMA) 12-4725. Rockville, 

MD: Substance Abuse and Mental Health Services Administration, 2012. 

http://www.samhsa.gov/dataINSDUH/2kIIMHFindingsandDetTables/2KIIMHFRlNSDUHmhfr2011.htm. 

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The growth of prescription drug abuse has touched providers, pharmacies, and beneficiaries in 

the Part D program. eMS recognizes that Part D plan sponsors face unique challenges in 

administering the Medicare prescription drug benefit. Part D plan sponsors can manage the 

benefit only at the beneficiary level, because they do not have access to Part D prescriber and 

pharmacy data beyond the transactions they manage for their own enrollees, which makes it 

more difficult to identify prescribers or pharmacies that are outliers in their prescribing patterns 

or are filling patterns relative to the entire Part D program. Unlike Medicare Advantage plans 

offering Part D, stand-alone plan sponsors face additional challenges because they manage only 

the drug benefit, which leaves plan sponsors without a direct relationship with the prescriber, 

while eMS manages the medical benefit. These plan sponsors operate under a different legal and 

regulatory framework than the traditional Medicare fee-for-service benefit. The ability of 

Medicare providers, pharmacies, and beneficiaries to abuse the Medicare prescription drug 

benefit is one symptom of the complex health care delivery system that must be addressed 

through broader reforms that result in better-coordinated carc. 

By focusing on stringent plan compliance and increased use of data analytics to identify outliers 

and suspicious prescribing patterns, we can provide Part D plans with the tools needed to prevent 

abuse, improve care, and ensure federal dollars are spent appropriately. As this public health 

challenge grows in size and scope, eMS is protecting our beneficiaries through new programs 

and technologies, such as enhanced Drug Utilization Review (DUR) procedures, increased use of 

analytics on prescriber and pharmacy data, and improved collaboration between Medicare Part D 

stakeholders. In addition, we are looking at ways we can leverage the administrative authorities 

we have to oversee fee-for-service providers and apply those same principles and techniques in 

the Part D program, where possible. Any policy response to Part D drug abuse must balance our 

desire to minimize prescription drugs abuse with the need to ensure access to prescription drugs 

for legitimate clinical use. 

Background on Medicare Part D 

The Medicare Part D prescription drug benefit program was established under the Medicare 

Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (P.L. 108-173). 

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Launched in 2006, Part D is designed to provide beneficiaries with access to drug coverage 

through private prescription drug plans. 

In Part D, eMS contracts with private entities-stand-alone prescription drug plan (PDP) 

sponsors, MA organizations, and other types of Medicare health organizations-who then act as 

the payers and insurers for prescription drug benefits. eMS pays sponsors on a per enrollee 

basis and the sponsors compete for enrollees based on premiums and coverage. In general, 

Medicare subsidizes about 75 percent of the average cost for basic coverage for beneficiaries 

who choose to enroll in the voluntary Part D benefit, and those beneficiaries pay the balance 

through monthly plan premiums. Additionally, some beneficiaries qualify for "extra help" 

through the Part D low-income subsidy program. 

All Part D sponsors are required to have a comprehensive plan to detect, correct, and prevent 

waste, fraud, and abuse. This plan consists of written policies, procedures, and standards of 

conduct that articulate the organization's commitment to comply with all applicable federal and 

state standards related to fraud and abuse. Sponsors must have a properly trained, effective 

compliance officer, and provisions for internal monitoring and auditing, as well as other 

requirements. These requirements help ensure that sponsors track and identify potential 

beneficiary or provider abuse. Chapter 9 of eMS's Prescription Drug Benefit Manual 18 

recommends that Part D sponsors generate and review reports, such as the following: 

• Prescription Drug Event (PDE) Payment Reports which detail for every prescription 

filled: (l) the amount paid by the Part D sponsor; (2) the pharmacy and provider 

identification numbers; (3) the beneficiary; and (4) a description of the drug, including 

dosage and amount. Part D sponsors use these reports to identify over- and underpayments, duplicate payments, timely payments, and pricing aberrances, and, also, to 

help verify correct pricing. 

• DURs which identify the number of prescriptions filled by an individual enrollee, and, in 

particular, the number of prescriptions for certain classes of drugs, such as narcotics, to 

identify potential therapeutic abuse or illegal activity by an enrollee. 

"Chapter 9 ofCMS' Prescription Drug Benefit Manual: http://www.cms.gov/Medicare/PreScliption-DrugCoveragc/PrescriptionDrugCovContra/downloads/PDBManual Chapter9 FW A.pdf 

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Prescribing Patterns by Physician Reports which identify the number of prescriptions 

written by a particular provider and typically focus on a class or particular type of drug 

such as narcotics. Part D sponsors generate these reports to identify possible prescriber, 

provider, or pharmacy fraud. 

CMS also contracts with a private organization, called the Medicare Drug Integrity 

Contractor (MEDIC), to assist CMS in managing its Part D audit, oversight, and anti-fraud 

efforts. The MEDIC's main functions include identifYing and investigating potential Part D 

fraud and abuse, developing potential Part D fraud or abuse cases for referral to law enforcement 

agencies, acting as a liaison to law enforcement, and collaborating with Part D sponsors on 

identification of potentially fraudulent schemes. The MEDIC is also responsible for auditing the 

anti-waste, fraud, and abuse compliance programs detailed above that are requirements for 

participation as a Part D sponsor. 

Medicare Prescription Drug Benefit Program Integrity Activities 

To combat prescription drug waste, fraud, and abuse more effectively, CMS evaluates Part D 

sponsors' operations to ensure that they are compliant with the regulations detailed above, as 

well as the guidance in the Prescription Drug Benefit Manual. As part of program oversight, 

CMS uses the Fraud Prevention System (FPS) in Medicare fee-for-service to target investigative 

resources to suspicious claims and providers and swiftly impose administrative action when 

warranted. Lessons learned from the FPS are providing insights into new methods and 

technologies to get ahead of people who would abuse the Part D program and identify their 

patterns of behavior early. CMS is now considering implementing similar strategies and 

administrative actions into its management of the Part D program and its sponsors to ensure a 

more systematic analysis of the claims data to prevent and detect abuse. 

Improving Data Analysis to Address Opioid Overutilization and Questionable Prescribing 

Patterns 

An individual beneficiary's behavior, such as "doctor shopping" to obtain frequently abused 

prescription drugs from multiple prescribers, may indicate fraud, waste, or abuse, and might also 

signal troubling patterns that endanger the beneficiary's health or indicate illegal selling of 

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63 

prescription drugs. DUR programs can help preserve program integrity, while also promoting 

safety, improving the quality of care, and preventing prescription errors. Part D plan sponsors 

must in place concurrent DUR programs for reviewing prescribed drug therapies at point-of-sale, 

as well as retrospective DUR programs for conducting ongoing, periodic examinations of claims 

data to identify patterns of inappropriate or medically-unnecessary prescription, dispensing, or 

use of prescription drugs. A concurrent DUR program must include screening for the following 

problems each time a prescription is dispensed: 

• Screening for potential drug therapy problems due to therapeutic duplication 

• Age/gender-related contraindications 

• Drug over-utilization and under-utilization 

• Drug-drug interactions 

• Incorrect drug dosage or duration of drug therapy 

• Drug-allergy contraindications 

• Clinical abuse/misuse of drugs 

Examining DUR-related analyses, claims data, and other records allows Part D sponsors to 

identify questionable utilization patterns that may indicate fraud, abuse, gross overuse, or 

inappropriate or medically-unnecessary prescription, dispensing, or use of prescription drugs. 

The Part D sponsors can also look for suspicious patterns associated with specific drugs or 

groups of drugs. Part D sponsors can then refer suspected fraud to CMS, the MEDIC, or a law 

enforcement agency, as appropriate. 

A 2011 GAO reportl9 found examples of potential egregious overutilization of medications by 

Part D beneficiaries who were obtaining opioid medications from multiple prescribers, with the 

vast majority of these beneficiaries receiving medications from between five and ten providers. 

Through discussions with the industry, CMS determined that sponsors need to employ more 

effective concurrent and retrospective DUR programs to address overutilization of medications 

to protect beneficiaries, and to reduce fraud, waste, and abuse in Part D. 

"GAO-11-699 "Medicare Part D: Instances of Ouest ion able Access to Presciption Dmgs" 

http://www.gao.gov/assets/590/585424.pdf 

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64 

CMS, through its Final Calendar Year 2013 Call Letter and subsequent guidance,20 outlined an 

approach to reduce potential opioid overutilization in the Part 0 program. Under this approach, 

Part 0 plans ensure safe dosages are dispensed through the improved use of concurrent claim 

edits and formulary utilization management design. CMS's guidance clarified that sponsors 

should clinically analyze cases for unsafe cumulative dosing that OUR programming has 

identified through patterns that suggest potential overutilization of drugs. 

The effective OUR program should include case management, outreach to providers, and, if 

necessary, beneficiary-level controls to prevent overutilization of opioid therapy and ensure 

beneficiary safety. During case management, clinical staff should communicate with prescribers 

and beneficiaries to understand the beneficiaries' medical needs. This clinician-to-clinician 

communication should result in beneficiaries receiving appropriate levels of medication through 

improved care coordination. 

If prescribers are non-responsive after multiple attempts, or prescribers concur that the current 

level of medication is unnecessary, a sponsor may implement beneficiary-level claim edits, but 

they must inform the beneficiary and their prescribers of those restrictions, and allow 

beneficiaries to appeal these restrictions. If a Part 0 sponsor implemented a point-of-sale edit for 

a beneficiary based on retrospective review, and that beneficiary then voluntarily changed to 

another plan, the initial sponsor should share this information with the subsequent sponsor so it 

can immediately implement similar beneficiary-level edits. CMS is monitoring Part 0 sponsors' 

implementation of the opioid overutilization policy, and if warranted, CMS will issue additional 

guidance to Part 0 sponsors identified from our oversight of the implementation of these 

measures. 

Additionally, CMS undertook a communication and educational campaign about medication 

overutilization, particularly opioids, for physicians and pharmacies in the fall of2012 to support 

sponsors' strengthened efforts to address this issue in the Part 0 program. In November 2012, as 

20 Final Calendar Year 2013 Call letter: http://www.cms.gov/Medicare/HealthPlans/MedicareAdvtgSpecRateStats/downloads/Announcement2013.pdf and August 31,2012 HPMS memo 

"Supplemental Guidance Related to Improving Drug Utilization Review Controls in Part D". 

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65 

part of the annual Medicare "Dear Doctor" letter (e.g, the "Announcement About Medicare 

Participation for Calendar Year 2013"), CMS encouraged prescribers to work with Part D 

sponsors on overutilization case management. To encourage further dialogue between CMS and 

Part D sponsors about overutilization, we also offered a session on overutilization at the 

Medicare Advantage and Part D Spring Conference in April 2012. 

Monitoring Prescribers and Pharmacies 

Part D is potentially vulnerable to fraud at the prescriber and pharmacy levels, as well. Providers 

and pharmacies may participate in drug diversion by participating in a "pill mill" scheme. This 

typically involves a pharmacy or other entity that pays kickbacks to a physician to write 

prescriptions for an illegal or inappropriate purpose so the pharmacy can bill for a Part D drug 

that is ultimately never dispensed. The HHS OIG, through a series of investigations, identified 

questionable Part D billing in 2009, including instances where PDE data contained invalid 

prescriber identifiers21 and where pharmacies billed extremely high dollar amounts or a high 

number of prescriptions per beneficiary, prescriber, or per type of drug. 22 

Over the last few years, CMS has taken a series of steps to ensure that valid prescriber identifiers 

accompany Part D claims and that the MEDIC and plan sponsors are monitoring pharmacy 

billing patterns. In 20 II, to enhance then existing practice and in collaboration with the Drug 

Enforcement Administration (DEA), we directed Part D sponsors to ensure that the prescriber 

identifier submitted on a PDE was active and valid starting in the 2012 coverage year, whether it 

be a national provider identifier (NPI), DEA number, unique physician identifier number, or state 

license number. Additionally, we began validating the format of all prescriber identifiers on 

PDEs that were coded as an NPI and excluded from payment reconciliation PDEs with invalid 

NPls. We began assessing each sponsor's performance regarding NPI use and validity and 

notified them of their performance. We also directed Part D sponsors to check that all 

prescriptions for controlled substances under Part D were associated with DEA numbers that 

indicated there was appropriate authority to prescribe the controlled substance. 

21 This refers to two upcoming reports. OEI-02-09-00603 "Prescribers with Questionable Patterns in Medicare 

Part D" and OEI-02-09-00608 "Medicare Inappropriately Paid for Drugs Ordered by Individuals Without 

Prescribing Authority" 

22 OEI-02-09-00600 "Retail Phannacies with Questionable Part D Billing" htlPs:lloig.hhs.gov/oei/reports/oei-02-09-

00600.pdf 

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66 

Through rulemaking finalized in 2012,23 CMS required Part D sponsors to submit PDEs with 

active and valid individual prescriber NPls, beginning January I, 2013. CMS, through the 

annual Medicare "Dear Doctor" letter, explained the NPI requirement to prescribers. CMS 

began to deny any PDE without an active and valid individual NPl beginning on May 6, 2013. 

We have continued to assess each sponsor's performance regarding NPI use and validity of 

submitted NPls and notified sponsors of their performance in preparation for this deadline. 

Based on this assessment, we found that 99.6 percent of the 2013 PDEs received during the first 

quarter of the coverage year reported the prescriber's NPI; all but 0.002 percent of the reported 

NPIs were valid and currently active or active within a year of the date of service. We also 

examined the taxonomy codes, which are self-reported by the providers to identify their 

specialty. We found 0.7 percent of these codes would be unreasonable for a prescriber. As a 

result, we have initiated a review of the PDEs reporting these NPls to determine what drugs were 

prescribed, if any are controlled substances, and if the prescriber has a valid individual DEA 

number. 

These actions ensure improved sponsor compliance with the PDE reporting requirements, 

enhance CMS's ability to review claims data to identify possible fraud and abuse, and help 

determine whether prescribers of controlled substances are writing prescriptions in accordance 

with their DEA registration. 

CMS has increased its monitoring of prescribers through the Part D Recovery 

Audit Contractor (RAC), with which CMS has contracted to identify and recover Part D 

improper payments. In 2011, CMS implemented the RAC program for Medicare Part D, and 

overpayment recoupment began in November 2012. The Part D RAC recently completed an 

analysis of PDE data to determine if any claims were prescribed by individuals or entities on 

OIG's List of Excluded Individuals and Entities (LEIE) for contract year 2007, and is currently 

reviewing LEIE data for contract years 2008 through 20 II. 24 

23 77 FR 54664: http://www.gpo.gov/fdsys/pkglFR-2012-09-05/pdf/2012-21238.pdf 

24 More information about Part D RACs is available at: http://www.cms.govlResenrch-Statistics-Data-nnd-

~msIMonitoring-Programs!recovery-audit-program-paI1S-c-and-diPart-D-Recovery-Audit-Contractor.html 

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67 

Additionally, in response to the concerns identified by recent HHS OIG reports and this 

Committee, we are currently exploring whether to use the Secretary's authority under 

section 6405 of the Affordable Care Act to require Medicare enrollment of the prescribing 

provider in order for the Part D program to cover the provider's prescriptions. This is similar to 

the Medicare fee-for-service rule that was finalized in April 2012. Based on CMS's experience 

with the FPS in Medicare fee-for-service and the critical reviews conducted by the HHS OIG, 

GAO, and this Committee, we have stepped up our efforts to take a cross-sectional look at our 

data to identify outliers or questionable patterns, particularly with respect to pharmacies. 

MEDICs are currently analyzing pharmacy data to detect anomalies, trends, patterns, and spikes 

to identify and refer to law enforcement pharmacies that present a fraud risk. We also plan to 

share this pharmacy data with Part D plan sponsors and will work with them to ensure they 

understand what actions they can take when conducting their own reviews of the outlier 

pharmacies. 

CMS also sends letters to Part D sponsors about fraud schemes that are being perpetrated across 

the country at the beneficiary, prescriber, and pharmacy levels. The letters summarize the 

schemes and explain how they are perpetrated, and encourage Part D sponsors to contact the 

appropriate MEDIC if they have encountered a similar scheme. 25 Part D sponsors may deny or 

reverse claims when they confirm such fraud scnemes.26 Sponsors may also terminate their 

contracts with indicted pharmacies, as contractually appropriate. This collaboration and 

information sharing allows CMS, Part D sponsors, and MEDICs to identify potential fraud and 

stop it before payment is made. 

Sharing Data to Fight Abuse 

The Affordable Care Act requires the centralization of certain claims data from CMS (Medicare, 

Medicaid, and the State Children's Health Insurance Program); the Department of Veterans 

Affairs; the Department of Defense; the Social Security Administration; and the Indian Health 

Service. Data-sharing makes it easier for agency and law enforcement officials to coordinate and 

25 To see an example ofa fraud alert, please visit: http://www.cll1s.govlMedicarefPrescription-DrugCoveragefPrescriptionDrugCovContraiDownloads/FraudAlert.pdf 

26 Guidance to sponsors about fraud alerts is available at: http://www.cms.govlMedicareIPrescription-DmgCoveragelPrescriptionDrugCovContraiDownloads/FraudAlertGuidance J 222 J I ,pdf 

II 
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identifY criminals and prevent fraud on a system-wide basis. eMS has an Integrated Data 

Repository (lOR), a data warehouse to integrate Medicare and Medicaid data so eMS and our 

partners can access data from a single source. The lOR provides a comprehensive view of 

Medicare data including claims, beneficiary, and drug information. The IDR provides greater 

information sharing, broader and easier access to data, enhanced data integration, and increased 

security and privacy of data, while strengthening our analytical capabilities. The lOR makes 

fraud prevention and detection efforts more effective by eliminating duplicative agency and lawenforcement efforts to identify and prevent waste, fraud, and abuse. 

The !DR is currently populated with seven years of historical Medicare Parts A, B, and D paid 

claims, and pre-payment claims data. These additional data may allow us to analyze previously 

undetected indicators of aberrant activity throughout the claims process. The One Program 

Integrity ("One PI") web-based portal shares data with our contractors and with law enforcement 

by providing a single access point to lOR data as well as analytic tools for reviewing the data. 

eMS is working closely with law enforcement to provide One PI training and support. 

Information technology also can help prescribers share data while improving the quality of care 

and clinical outcomes, while also reducing fraud, waste, and abuse in Part D. E-prescribing can 

reduce instances of unauthorized, improperly altered, and counterfeit prescriptions. For 

example, in Part D, an e-prescribing system could show the clinician the patient's real-time 

medication history across all providers. The e-prescribing tool may indicate if a prescription was 

filled, what the dosage was, and who prescribed it and when. These data may indicate if the 

patient is "doctor shopping" for pain medications or other misused drugs. Hospital emergency 

department doctors appreciate e-prescribing for this reason, as they often struggle to distinguish 

between an attempt to get medications fraudulently, versus a true medical complaint. An 

electronic health record with an e-prescribing function provides a more complete picture because 

it offers the service utilization history, diagnoses, lab results, and other data that can help 

clinicians determine the best course of treatment and ifthere is potential fraud or abuse involved, 

and is part of the meaningful use requirements. 

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Collaborating with Part D Stakeholders 

CMS's approach to program integrity once involved stand-alone programs with siloed 

communications that did not engage other Federal partners or allow for shared best practices. 

Now, however, thanks to a variety of efforts, Federal, state, and local law enforcement health 

care fraud activities are being coordinated to a greater extent than ever before. CMS is also 

engaging with the private sector in new ways to better share information to combat fraud. 

CMS has established collaboration between program officials and law enforcement as a critical 

cornerstone in improving health care fraud detection and investigation. As a natural progression 

from early collaborative meetings, on July 31, 2012, CMS opened the Command Center, which 

provides the advanced technologies and collaborative environment for a multi-disciplinary team 

of experts and decision makers to more efficiently coordinate policies and case actions, reduce 

duplication of efforts, and streamline fraud investigations for more immediate administrative 

action. Since its opening, the Command Center has supported 61 missions that included over 

450 unique participants from CMS and our partners, including the HHS OIG and the Federal 

Bureau of Investigations (FBI). Earlier this month, the Command Center held an all-day 

collaborative workgroup about prescription drug fraud; participants included CMS, the MEDIC, 

a representative from Florida's Medicaid Program Integrity Unit, a Medicaid Fraud Control Unit, 

and the HHS OIG. They outlined current efforts to prevent and fight prescription drug fraud, 

discussed barriers and gaps, shared analysis results, and presented new trends. 

In addition to CMS's commitment to collaboration, the sustained success of the Health 

Enforcement Action Team (HEAT) demonstrates the effectiveness of the Cabinet-level 

commitment between HHS and the Department of Justice (DOJ) to prevent and prosecute health 

care fraud. Since its creation in May 2009, HEAT has played a critical role in identifying new 

enforcement initiatives and expanding data sharing to a cross-government health care fraud data 

intelligence-sharing workgroup. A key component of HEAT is the presence of Medicare Strike 

Force Teams, interagency teams of analysts, investigators, and prosecutors, who target emerging 

or migrating fraud schemes such as criminals masquerading as healthcare providers or suppliers. 

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70 

Medicare Strike Force Teams coordinated three major takedowns in 2012, and CMS took 

administrative action against 160 providers and suppliers associated with those law enforcement 

activities. One major takedown included a Miami pharmacy owner who was sentenced to 

14 years in prison for a $23 million health care fraud scheme involving illegal kickbacks to 

physicians in exchange for prescription referrals, which the pharmacies ultimately billed to 

Medicare. 27 

In addition to collaborating with other agencies, CMS is partnering with the private sector in 

anti-fraud efforts. Last year, HHS and DO] announced the creation of a voluntary, collaborative 

Healthcare Fraud Prevention Partnership, involving the Federal Government, state officials, 

private health insurance organizations, and other health care anti-fraud groupS.28 The goal of this 

collaboration is to improve fraud detection and prevent payment of fraudulent health care 

billings by finding and stopping schemes that cut across public and private payers. CMS and the 

MEDICs also host quarterly Part C and Part D Working Groups, during which plan sponsors 

share their experiences with fraud schemes. 

Finally, CMS works with the states to address prescription drug abuse. States began to monitor 

and prevent prescription misuse and abuse more than 60 years ago by creating programs to track 

the dispensing of prescription drugs. Currently, 49 states have enacted legislation authorizing 

Prescription Drug Monitoring Programs (PDMPs), and 46 states have operational PDMPs29 

PDMPs aim to detect and prevent the diversion and abuse of prescription drugs at the retail level 

by tracking controlled substances prescribed by authorized practitioners and dispensed by 

phannacies, including those dispensed to Part D beneficiaries. CMS, through the annual 

Medicare "Dear Doctor" letter, encouraged prescribers to use PDMPs. CMS also distributed an 

27 More information is available at http://www.justice.gov/opa/pr/2013/FebruaryIl3-crm-233.html. 

28Among the first to join this partnership are: America's Health Insurance Plans, HHS (including CMS and 

HHS OIG), DOJ (including FBI), Amerigroup Corporation, Blue Cross and Blue Shield Association, Blue Cross 

and Blue Shield of Louisiana, Coalition Against Insurance Fraud, Humana Inc., Independence Blue Cross, National 

Association oflnsurance Commissioners, National Association of Medicaid Fraud Control Units, National Health 

Care Anti-Fraud Association, National Insurance Crime Bureau, New York Office of Medicaid Inspector General, 

Travelers, Tufts Health Plan, UnitedHealth Group, and WellPoint, Inc. 

2. Status of Prescription Drug Monitoring Programs (PDMPs), PDMP Training & Technical Assistance Center, 

available at http://pdmpassist.org/pdflpmpprogramstatus2013.pdf (last revised June 5, 2013). 

14 
71 

article to encourage physicians to use their state PDMPs in the December 2012 issue of the Medicare 

Learning Network. 

The President's Fiscal Year (FY) 2014 Budget includes proposals to build on these efforts. The 

first proposal would requirc states to monitor high-risk billing activity in the Medicaid program 

to identify prescribing and utilization patterns that may indicate abuse or excessive utilization of 

certain prescription drugs. This proposal, if enacted, would ensure that all states have efforts in 

place to track high utilizers, and is estimated to save $1.8 billion over ten years. The 

Administration is evaluating the utility of state PDMPs for reducing Medicare and Medicaid 

fraud as called for in President Obama's prescription drug abuse prevention action plan. lO The 

second proposal would invest $640 million ($311 million base discretionary funding and 

$329 million proposed mandatory funding) in the Health Care Fraud and Abuse Control Program 

in FY 2014, to support efforts to reduce fraud through initiatives such as the HEAT task force 

and the Health Care Fraud Prevention Partnership. 

Conclusion 

CMS's role in the Part D program is not to just pay for drug coverage, but to ensure the best 

possible care for its beneficiaries. As evidenced by my testimony today, we are addressing the 

serious issues raised by the Committee, HHS oro, and the OAO through a number of reforms, 

including enhanced Medicare provider screening, advanced data analysis, and improved 

stakeholder collaboration to change how we approach waste, fraud and abuse and improve the 

accuracy of our payments. CMS is broadening its focus from ensuring beneficiaries have access 

to prescribed drugs to ensuring that Part D sponsors implement effective safeguards and provide 

coverage for drug therapies that meet standards for safety and efficacy. eMS will continue to 

work with the Congress and this Committee in protecting taxpayer dollars, beneficiary health, 

and the integrity of the Medicare program. 

30 Epidemic: Responding /0 America's Prescription Drug Abuse Crisis. Executive Office of the President of the 

United States. 2011. http://www. whitehollse.gov/sites/default/files/ondcplissues-contentipreseriptiondrugslrx abuse plan O.pdf 

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72 

Testimony of: 

Gary Cantrell 

Deputy Inspector General for Investigations 

and 

Stuart Wright 

Deputy Inspector General for Evaluation and Inspections 

Office of Inspector General 

U.S. Department of Health and Human Services 

Hearing: 

Curbing Prescription Drug Abuse in Medicare 

Senate Committee on Homeland Security 

and Governmental Affairs 

June 24, 2013 

Dirksen 342 

3:00 PM 
73 

Testimony of: 

Gary Cantrell 

Deputy Inspector General for Investigations 

and 

Stuart Wright 

Deputy Inspector General for Evaluation and Inspections 

Office of Inspector General 

U.S. Department of Health and Human Services 

Good afternoon Chairman Carper, Ranking Member Coburn, and other distinguished Members 

of the Committee. The Office ofInspector General's (OIG) testimony today discusses 

prescription drug fraud schemes; vulnerabilities in the Medicare Part D Prescription Drug 

program (Part D); and recommendations to protect the program against fraud, waste, and abuse 

and to protect program beneficiaries from harmful and unsafe prescribing. 

With $66.9 billion in expenditures and 37.4 million beneficiaries enrolled, 1 it is essential that 

various players work together to protect the integrity of the Part D program and the health and 

welfare of the people it serves. Combating fraud, waste, and abuse involves a number of key 

partners, including the Centers for Medicare & Medicaid Services (CMS), CMS's contractor 

called the Medicare Drug Integrity Contractor (MEDIC), Part D plan sponsors, and the Drug 

Enforcement Administration (DEA), State Medicaid agencies, and State and local law 

enforcement. CMS is responsible for overseeing the program and paying plan sponsors; the plan 

sponsors are responsible for preventing and detecting fraud, waste, and abuse and appropriately 

paying for drugs under Part D; and the MEDIC is responsible for identifying and investigating 

potential fraud and abuse, as well as referring cases to law enforcement. OIG often partners with 

DEA, the agency responsible for enforcing the controlled substances laws and regulations, on 

cases where we have dual jurisdiction. 

Since the inception of Part D, OIG has extensively examined the monitoring and oversight of the 

program and the effectiveness of controls to ensure appropriate payment and patient safety. Our 

work has found limitations in program safeguards that leave Part D vulnerable to fraud, waste, 

and abuse and Medicare patients vulnerable to potentially harmful prescribing. Notably, OIG 

has uncovered extreme prescribing patterns by hundreds of general-care physicians and 

questionable billing by thousands of retail pharmacies. Moreover, in a report we are releasing 

today, we found that Medicare paid millions of dollars for prescriptions from unauthorized 

prescribers, such as massage therapists and athletic trainers. 

These vulnerabilities are even more concerning in light of our increasing investigations into drug 

diversion. Since 2008, OIG's investigations relating to Medicare Part D have nearly quadrupled. 

'The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 

2013 Annual Report of the Boards ofTruslees of the Federal Hospilallnsurance and Federal Supplementary 

Medicare Insurance Trust Funds, p. 10. 2 The Centers for Disease Control and Prevention (CDC) characterized 

prescription drug abuse as an epidemic. In 2010, for example, overdoses of prescription painkillers were among the 

leadin causes of accidental death in the United States. 

Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
74 

The serious and growing problem of prescription drug abuse lends a greater urgency to address 

drug diversion and to improve monitoring and oversight of the Part D program. 2 

Drug Diversion Is a Complex Crime Involving Many Co-Conspirators 

Prescription drug diversion is a complex crime that can involve many co-conspirators---drug 

distributors and traffickers, health care professionals, drug-seeking patients, and pharmacies may 

all playa role, and criminal enterprises are becoming an increasing presence in prescription drug 

diversion. 

Drug distributors, traffickers, and criminal enterprises 

Prescription drug diversion often involves drug distributors and traffickers. 3 Criminal 

enterprises have also historically been engaged in the illegal drug trade. Of concern is that they 

are becoming an increasing presence in OIG's prescription drug diversion cases and represent a 

greater risk to our law enforcement officers, witnesses, and others engaged in investigating this 

crime. They frequently associate with and use other criminals, such as identity thieves and 

money launderers, to facilitate the fraud scheme. 

Health care providers 

Medical doctors, physician assistants, nurse practitioners, and other health care professionals can 

also be involved in drug diversion. Some health care providers become so entangled in the 

financial gain from prescription drug diversion that their entire practices are focused on writing 

illicit prescriptions. Clinics or health care practices that focus primarily on prescription drug 

diversion are known as "pill mills." While some providers bill for medical services that were 

never rendered and simply provide prescriptions to the patients, others may provide medically 

unnecessary and potentially harmful services to increase their financial profits. Some health care 

providers that engage in drug diversion schemes also struggle with prescription drug addiction. 

Drug-seeking patients 

Drug-seeking patients often visit multiple health care providers and pharmacies to obtain 

medically unnecessary prescriptions. Some use multiple false identities and may themselves be 

identity thieves. Drug-seeking patients often consume the drugs, sell them on the street for 

profit, or both. 

2 The Centers for Disease Control and Prevention (CDC) characterized prescription drug abuse as an epidemic. In 

20 I 0, for example, overdoses of prescription painkillers were among the leading causes of accidental death in the 

United States. 

J According to DEA, a prescription drug distributor is a person who is selling, furnishing, or delivering a controlled 

substance. The offense of drug trafficking refers primarily to the weight of the substances involved. Both 

distributors and traffickers may use multiple false identities in committing the crime. 

http://www.getsmartaboutdrugs.com/identify/what is distribution whats drug trafficking.hlml 

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Some criminals, often known as "recruiters," target locations where drug-seeking patients are 

known to gather and offer them money for the use of their Medicare or Medicaid numbers. In 

some cases, recruiters offer several hundred dollars to drug-seeking patients to be transported to 

multiple medical appointments and then bill Medicare or Medicaid for those services. 

Of particular concern are those cases when patient deaths occur as a result of the prescription 

drug diversion scheme. These are generally associated with "pill mills," which are sometimes 

advertised as pain management clinics. One particular pain management clinic was associated 

with the deaths of over 60 patients in a 5-year period. The patients were billed for minimal 

services or services that were not rendered and were required to return monthly to receive their 

prescriptions, without regard for medical necessity. The doctor and his wife were sentenced to 

over 30 years of imprisonment and ordered to pay $114,772,524 in restitution to several 

government and private insurance plans and individuals. 

Pharmacies 

Pharmacies also playa role in drug diversion. Fraudulent pharmacies have been known to use 

patient Medicare numbers to bill for tens of thousands of dollars in unneeded prescriptions. In 

some fraud schemes, pharmacies stock or re-label expired and counterfeit medications and bill 

for them and sell them as legitimate prescriptions to unsuspecting patients. They may also bill 

for recurring refills that were never filled. Other pharmacies contribute to the fraud by filling 

prescriptions despite clear indicators they have been fraudulently obtained. Some pharmacies 

are even complicit in the scheme by paying patients with cash or narcotics to fill illegitimate and 

expensive prescriptions at their locations. 

In one particular case, a licensed pharmacist who owned 26 pharmacies was the mastermind of a 

scheme that used an elaborate web of physicians, pharmacists, and patient recruiters to 

fraudulently bill Part D, Medicaid, and private health insurance carriers. This pharmacist paid 

kickbacks, bribes, and other inducements to physicians to write prescriptions for controlled drugs 

and expensive noncontrolled drugs. In addition, the physicians billed for services that were 

medically unnecessary or were never provided. The physicians directed their patients to fill their 

prescriptions at 1 of the 26 pharmacies, which then billed Medicare and Medicaid for expensive 

noncontrolled drugs but did not dispense them. The pharmacist then took his existing physical 

inventory of expensive noncontrolled drugs, repackaged them, and sold them to pharmaceutical 

suppliers. The pharmacist responsible for this egregious scheme was convicted along with 5 

other connected individuals at trial, and an additional 14 conspirators have entered into plea 

agreements and await sentencing. 

A unique set of fraud schemes involves what are termed as "phantom pharmacy" and "bust-out" 

schemes. Phantom pharmacies exist virtually or perhaps in an abandoned warehouse or office 

storefront. There is no legitimate pharmacy that provides services, but the pharmacy itself has an 

address or a P.O. box, a Medicare billing number, a bank account, and an electronic funds 

transfer number for transferring funds into the bank account. The identities of doctors, 

pharmacists, and patients are often stolen to perpetuate the fraud. 

4 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
76 

Another variation of this theme involves "bust-out" pharmacies, i.e., usually a small pharmacy 

that is about to go out of business. The pharmacy owner may advertise online or in the 

newspaper that the pharmacy is for sale with an active Medicare number. If the pharmacy is 

purchased by a criminal involved in the prescription drug diversion trade, it bills Medicare a 

large amount in a short period of time, collects the proceeds, and disappears. 

It is important to note that prescription drug diversion cases investigated by OIG are not limited 

to controlled substances. OIG also has investigated matters that involve noncontrolled but highcost prescriptions, such as respiratory, anti-psychotic, and HIV/AIDS medications. In one 

particular case, a pharmacy billed for very expensive medications that included anti-psychotics 

and respiratory and cardiac drugs but never dispensed the drugs. The perpetrators of this scheme 

were sentenced to 57 months of imprisonment and ordered to pay $4.9 million in restitution. 

With the rise in prescription drug abuse, concerns about Medicare fraud, particularly pharmacy 

and prescriber fraud, have increased. These concerns are reinforced by ~iG's recent evaluations, 

which focus on unauthorized prescribers, questionable prescribing patterns, and questionable 

billing by pharmacies for Part D drugs. 

Medicare Paid for Drugs Ordered by Individuals Without the Authority To Prescribe 

In the report that we are releasing today, OIG found that one of the most basic safeguards - that 

an item or a service was performed, provided, or prescribed by an appropriate medical 

professional is not always operating effectively. 

To be covered under Part D, drugs must be prescribed in accordance with State law, which 

specifies the types of health care providers that have the authority to prescribe drugs in the State. 

We found that, nationwide, Part D inappropriately paid $5.4 million in 2009 for 72,552 

prescriptions ordered by individuals who clearly did not have the authority to prescribe. These 

individuals included massage therapists, athletic trainers, dental hygienists, and contractors 

responsible for home repairs. We even found that interpreters, lodging companies, and 

veterinarians ordered prescriptions. Medicare should never pay for drugs ordered by these 

individuals. 

Additional1y, in 10 States that we reviewed in depth, Part D inappropriately paid for drugs 

ordered by others who did not have the authority to prescribe. These included counselors, social 

workers, chiropractors, registered nurses, physical therapists, occupational therapists, and 

speech-language pathologists. In total, we identified almost 350,000 prescriptions ordered by 

these prescriber types in the 10 States. Part D paid $26.2 million for these drugs. It is important 

to note that our review focused on selected types of providers; they do not represent all provider 

types without the authority to prescribe. 

Further, tens of thousands of drugs ordered by individuals without prescribing authority were 

controlled substances. These drugs are of particular concern because they have potential for 

abuse. 

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June 24, 2013 
77 

We found many examples in which Medicare paid for drug claims in which the prescribers were 

individuals without the authority to prescribe: 

• One Florida massage therapist was listed as the prescriber on 3,756 prescriptions, amounting 

to $183,132. 

• An Ohio social worker was listed as the prescriber on 1,639 prescriptions, which were all 

filled at I retail phannacy. 

• A registered nurse from California was listed as the prescriber on 1, III prescriptions, which 

were filled at a single retail phannacy in New York. 

From the claims data, we could not detennine whether the drugs were actually ordered by the 

unauthorized individuals listed on the claims or whether the providers' identification numbers 

were being misused. Either scenario is problematic and resulted in inappropriate payments and 

may have put patients' health and safety at risk. 

These findings build on earlier OIG work that found that Part D paid for prescription drugs for 

which the claims had invalid prescriber identifiers. Specifically, in 2007, Part D sponsors and 

beneficiaries paid phannacies $1.2 billion for claims that contained prescriber identifiers that had 

never been assigned or had been retired. For almost one-fifth of these claims, the prescriber 

identifiers did not meet the fonnat specifications, yet sponsors' systems did not include edits to 

reject or flag claims with obviously inaccurate prescriber identifiers. For example, for some 

claims, the prescriber identification field contained the wrong number of characters. 

CMS has reported taking several steps to address the problems we identified with invalid 

prescriber identifiers. CMS now requires that sponsors ensure that prescriber identifiers on 

Part D claims are active and valid. Today's report demonstrates the need for further action to 

ensure that each claim for a prescription contains not only a valid prescriber identifier but also 

one that corresponds to an authorized prescriber. 

Hundreds of Physicians Had Extreme Prescribing Patterns 

Vulnerabilities in the Part D program are not limited to unauthorized prescribers. In a report 

issued last week, OIG raised concerns about questionable prescribing patterns for 736 generalcare physicians. These physicians were extreme outliers and prescribed very differently than 

their peers-they ordered an extremely high number of drugs per beneficiary; they had 

prescriptions filled at an extremely high number of phannacies; they ordered extremely high 

percentages of brand-name drugs; or they ordered extremely high percentages of Schedule II or 

Schedule III drugs, which have the potential for abuse. 4 These drugs include oxycodone and 

morphine. 

4 Drugs and other substances that are considered controlled substances under the Controlled Substances Act are 

divided into five schedules. Drugs are placed on a certain schedule on the basis of having a medically accepted use 

in treatment in the United States, their potential for abuse, and the likelihood that dependence will result from that 

abuse. 

6 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
78 

Our analysis identified many examples of questionable prescribing patterns. A couple of them 

include: 

• Medicare paid a total of $9.7 million-lSI times more than the average-for 1 California 

physician's prescriptions. Most of this physician's prescriptions were filled by just two 

independent pharmacies, both of which OIG identified in a prior review as having 

questionable billing. 

• Seventy-eight percent of the prescriptions ordered by one Florida physician were for 

Schedule Il drugs. Schedule II drugs have the highest potential for abuse of any prescription 

drugs legally available in the United States. This physician prescribed massive amounts of 

Schedule II drugs for a single beneficiary, including a 20-month supply of morphine sulfate 

and a 17-month supply of oxycodone HC\. 

In total, Medicare paid $352 million for Part D drugs ordered by the physicians with 

questionable prescribing patterns in 2009. Notably, 110 of these physicians were associated with 

1 or more of the retail pharmacies we identified as having questionable billing as discussed 

below. 5 It is important to note that questionable billing does not necessarily mean fraudulent 

billing. However, these patterns raise flags that warrant further attention. 

Thousands of Retail Pharmacies Billed Far Outside the Norm 

Our prior analysis of Part D data also uncovered disturbing billing patterns by some pharmacies. 

When we examined the records for Part D drugs, we found that 2,637 retail pharmacies 

nationwide had billing patterns far outside the norm. These pharmacies billed extremely high 

numbers of drugs per beneficiary or per prescriber or billed extremely high percentages of 

Schedule II or Schedule III drugs, brand-name drugs, or refills relative to other pharmacies. 

While some pharmacies with questionable billing may be billing these amounts for legitimate 

reasons, this type of billing warrants further scrutiny. Medicare paid these pharmacies a total of 

$5.6 billion in 2009. 

We uncovered many examples of pharmacies billing far outside the norm: 

• One pharmacy had 85 percent of its total prescriptions for the year ordered by a single 

prescriber. Billing patterns like this may indicate that the pharmacy and prescriber were 

working together to defraud the Part D program. 

• One pharmacy billed an average of$132,845 per prescriber, which is 73 times the national 

average. Virtually all of these prescriptions were for brand-named drugs. These included 

Dovonex (a drug that treats psoriasis), Zyprexa (an antipsychotic), and Flovent HFA (a drug 

that treats asthma). 

5 We considered a physician to be associated with a retail ph,nnacy if the retail pharmacy billed for at least 25 

percent of the total cost of the Part D drugs that hysician prescribed in 2009. 

7 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
79 

Medicare Paid for Schedule II Drugs Billed as Refills, Which Are Prohibited by 

Federal Law 

In another review, we found that Medicare Part D inappropriately paid $25 million for 

Schedule II drugs billed as refills in 2009. Sponsors should not have paid for any of these drugs 

because Federal law prohibits the refilling of Schedule II controlled substances. A new 

prescription authorizing the pharmacy to provide the drug is required each time a Schedule II is 

dispensed. Paying for refills of highly addictive drugs raises public health concerns and may 

contribute to the diversion and resale of controlled substances. Some of these refills may have 

been inaccurately billed. However, three-quarters of Part D sponsors paid for these refills, 

indicating that many sponsors do not have adequate controls in place to prevent refills of 

Schedule II drugs. 

Oversight and Monitoring by CMS, Plan Sponsors, and CMS's Contractor Are Limited 

OIG's findings of claims for questionable, inappropriate, and potentially dangerous Part D drugs 

indicate that safeguards should be strengthened to better protect the program and beneficiaries. 

In addition to analyzing these claims, we have examined Part D oversight and the systems in 

place to protect program integrity. These reviews have focused on CMS's oversight functions; 

plan sponsors' identification of fraud and abuse; and the MEDIC's abilities to detect, investigate, 

and refer fraud in the Part D program. 

All these reviews have identified vulnerabilities in efforts to combat Part D fraud and abuse. For 

example, we found that some plan sponsors did not identify any potential fraud and abuse 

incidents and that most potential fraud and abuse incidents were associated with only a small 

number of plan sponsors. 

Further, the MEDIC has not fully utilized data analytics to identify potential fraud and abuse. 

CMS's plans had called for data analysis to serve as a cornerstone of its Part D integrity strategy. 

However, OIG's work revealed that only a small percentage of the MEDIC's investigations and 

case referrals originated through proactive methods, such as data analysis. 

The MEDIC also faces challenges in effectively resolving instances of potential fraud, waste, or 

abuse. For example, there is no administrative mechanism to recover payments associated with 

inappropriate Part D claims. The MEDIC is also prohibited from sharing specific information 

with program integrity contractors that oversee Medicare Parts A and B and Medicaid. Further, 

the MEDIC lacks the authority to obtain information directly from pharmacies, physicians, and 

pharmacy benefit managers; it must obtain information through the plan sponsors. Finally, CMS 

does not require plan sponsors to refer instances of suspected fraud and abuse to the MEDIC, so 

it may be missing opportunities to develop and pursue fraud cases. 

DIG Recommends Improvements in Part D Oversight and Monitoring 

Taken together, orG's findings consistently demonstrate the need for CMS to strengthen Part D 

monitoring and oversight. OIG has recommended numerous improvements to more effectively 

safeguard the Part D program from fraud, waste, and abuse. We have recommended that CMS: 

8 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
80 

Require sponsors to verify that prescribers have the authority to prescribe drugs. 

• Strengthen the MEDIC's monitoring of prescribers and pharmacies so that it systematically 

monitors them using measures such as the ones used by OrG and identifies the prescribers 

and pharmacies with questionable patterns. 

• Strengthen sponsors' monitoring of prescribers and pharmacies by providing additional 

guidance on effective monitoring methods, emphasizing the importance of data analysis, and 

recommending that sponsors routinely generate and review reports on billing. 

• Ensure that Part D does not pay for refills of Schedule II drugs, as such refills are prohibited 

by Federal law. CMS should exclude these drugs when calculating its final payments to 

sponsors at the end of each year. 

• Require sponsors to refer potential fraud and abuse incidents that may warrant further 

investigation to CMS and other appropriate entities, instead of relying on sponsors to 

voluntarily report. 

• Develop and implement an administrative mechanism to recover payments from plan 

sponsors for inappropriate Part D claims. CMS currently does not have such a mechanism to 

help safeguard Medicare funds. 

• Clarify its policy and instruct the MEDIC regarding the circumstances under which it may 

share specific information with other entities, including State agencies. This would improve 

the MEDIC's ability to effectively identify and investigate potential fraud and abuse. 

• Facilitate access to information necessary to ensure accurate coverage and reimbursement 

determinations. Requiring diagnosis codes on Part D claims could help plan sponsors and 

CMS determine whether a drug is covered under Medicare. 

• Amend regulations to authorize the MEDIC to obtain information directly from entities such 

as pharmacies, physicians, and pharmacy benefit managers. 

• Provide education and training for prescribers, including issuing reports similar to 

Comparable Billing Reports issued for other services, such as those provided under Part B. 

These reports would provide prescribers with important educational information and insight 

about their prescribing patterns. 

CMS has agreed with many of our recommendations and it has taken some steps to strengthen 

Part D monitoring. While we appreciate CMS's agreement to implement certain 

recommendations, many of the vulnerabilities that orG has identified stem from a lack of basic 

checks that should be occurring. It is important that CMS effectively follow through and 

implement these basic checks. OrG's next steps in oversight will be to review the effectiveness 

9 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
81 

of sponsors' drug utilization programs to ensure that Medicare payments meet program 

guidelines. 

Conclusion: More Needs To Be Done To Safeguard tbe Program and Protect Patient 

Safety 

The Part D program provides outpatient prescription drug coverage for 37 million Medicare 

beneficiaries at a cost of almost $67 billion. Numerous health care fraud investigations 

involving Part D and drug diversion have revealed complex crimes, some involving criminal 

enterprises. Ineffective or nonexistent program controls can cost beneficiaries and taxpayers 

millions of dollars. In addition, serious health consequences can result from inappropriate 

prescription drug use. Effective monitoring and oversight are essential to ensuring patient safety 

and preventing fraud, waste, and abuse. 

To that end, all of the players discussed in OIG's testimony need to do more. CMS needs to 

improve its oversight and take the specific steps outlined above. The MEDIC needs to improve 

its monitoring of claims data and effectively develop and refer potential fraud cases to OIG. 

Sponsors need to strengthen their payments controls and reporting of fraud and abuse. The 

program needs effective controls that prevent problems from occurring and effective and 

aggressive responses in instances when problems occur. 

For our part, OIG is committed to continuing our vigilant oversight of Part D integrity and 

investigating cases of suspected fraud to hold perpetrators accountable and protect beneficiaries. 

This mission is challenged by the declining resources that OIG has to bring to bear at a time 

when Part D fraud, waste, and abuse and prescription drug diversion cases are on the rise. While 

our Part D investigative caseload has almost quadrupled over the past 5 years, we are in the 

process of reducing our staff by about 20 percent as a result of expiring funding sources, 

compounded by the effects of sequestration. We are leveraging our analytic, investigative, and 

oversight tools as well as our Federal, State, and local partnerships to maximize the impact of our 

efforts. 

Thank you for your interest in this important issue and for the opportunity to present the results 

of our most recent work related to Part D. OlG remains committed to carrying out our oversight 

and enforcement responsibilities in this area as comprehensively and effectively as possible with 

the tools and resources we have available. 

1 0 Senate Committee on Homeland Security and Governmental Affairs 

June 24, 2013 
82 

TESTIMONY 

Curbing Prescription Drug Abuse in Medicare 

Ms. Alanna M. Lavelle 

Director, Special Investigations 

WeliPoint, Inc. 

3350 Peachtree Road, Atlanta, GA 30326 

United States Senate 

Committee on Homeland Security & Government Affairs 

Monday, June 24, 2013: 

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Mr. Chairman and members of the Senate Committee on Homeland Security and Government 

Affairs, I am Alanna Lavelle, Director of Special Investigations for WellPoint, Inc. WellPoint is 

one of our nation's largest companies providing health and ancillary benefits to consumers and 

businesses, with nearly 36 million people in our affiliated health plans, and nearly 68 million 

people served through our subsidiaries. I also serve as the Chair of the National Health Care 

Anti-Fraud Association, the leading national association composed of both private and public 

sectors focused exclusively on fighting health care fraud and abuse. I joined WellPoint in 2004, 

after serving 25 years with the FBI. My experience in the FBI included managing a national 

health care fraud case during the critical ColumbialHCA investigation and initiating the first 

Health Care Fraud Task Force in Texas. I also served as the Supervisory Special Agent FBI 

liaison for the Centers for Disease Control (CDC), working closely with the CDC on 

Bioterrorism matters in the post 9111 era. I am a registered Mediator and a Certified Professional 

Coder. I hold a M.S in Conflict Management and a B.A. in International Relations. 

Thank you for the opportunity to provide testimony on behalf of WellPoint on a critically 

important issue that often yields tragic results: prescription drug abuse in the health care delivery 

system. 

As one of the largest health benefits companies with nearly 36 million lives in our 

affiliated health plans, WellPoint believes that it is critical to address health care fraud and abuse. 

In a time of rising health care costs, it is essential to stop funding illegitimate uses of prescription 

drugs. The National Health Care Anti- Fraud Association estimates that financial losses due to 

health care fraud and abuse range from $70 to $234 billion a year - about $190 to $640 million 

per day. At WellPoint, we have a number of innovative strategies in place to do OUf part to 

eliminate wasteful spending. 

However, the cost goes beyond the billions of dollars consumers, payers and the 

government spend unnecessarily. It also puts consumers' health at risk. For example, the 

steadily increasing incidence of physicians overprescribing narcotics that are not medically 

necessary contributes to inappropriate drug use by teenagers, patient overdoses and even death. 

In order to truly make inroads into the problem of fraud and abuse associated with 

prescription drugs, a holistic view needs to be adopted, since the enormous costs of health care 

fraud are borne by all Americans, whether they have private health insurance coverage or 

government-provided health care. Moreover, it is clear that many of the same individuals and 

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entities that perpetrate fraud against government health care programs also engage in fraudulent 

activity in the private health insurance industry. Thus, the most effective way to address 

prescription drug fraud and abuse is to forge a close and active partnership between private 

health plans, government agencies, and the provider community. Fraud and abuse affects both 

publicly funded health care programs and privately funded health benefits - and it is only 

through cooperation and collaboration between the public and private sectors that the problem 

can be meaningfully addressed. 

In addition, it is important to understand that stopping prescription-drug fraud and abuse 

will require a multifaceted approach, as there is more than one problem and more than one 

source. For example, drug fraud or abuse can be caused by overutilization (drug abuse) or 

fraudulent prescribing (for financial gain), and can be driven not only by the recipients of the 

drugs but also by prescribing providers. In addition, new schemes to defraud the system are 

constantly changing and evolving. For this reason, it is important to recognize that a one-sizefits-all solution does not exist. WellPoint stands ready to share with policymakers its range of 

experience in fighting prescription drug fraud and abuse and to work together with Congress, the 

Administration, and the agencies of jurisdiction to improve our partnership in this regard. 

One of the significant strengths that WellPoint and other health plans provide is the data 

available from our integrated health care delivery system. This allows us the ability to see the 

entire health care spectrum and spot trends and outliers - such as the overprescribing physician 

or the patient receiving mUltiple prescriptions from multiple providers or pharmacies. For 

WellPoint's members that have both pharmacy and medical coverage under WellPoint, we have 

been able to identify: 

• Members in crisis or at risk of harmful prescription drug use, including abusive or 

potentially addictive usage patterns; 

• Members who may benefit from chemical dependency and/or pain management 

intervention to improve quality of life; 

• Provider practice patterns regarding the overprescribing of medications; and 

• Criminal enterprise and/or individuals defrauding the health care system, through 

the work of our fraud and abuse Special Investigations Unit (sru). 

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Our goal at WellPoint is to prevent prescription drug fraud and abuse for the benefit of 

our members' health, as well as for the health care system as a whole. In order to meet this goal, 

Well Point has developed numerous programs to identifY prescription drug abuse and to intervene 

when appropriate. 

WeliPoint's Special Investigations Unit 

To enhance our efforts to combat fraud and abuse, WellPoint has a dedicated fraud and 

abuse prevention team known as the Special Investigations Unit (SIU). I am one of the lead 

investigators, overseeing a team in the Southeast region. The SIU, led by a former Los Angeles 

Assistant United States Attorney, is staffed with employees having prior experience in the FBI, 

state law enforcement, and state insurance department fraud units. Medical professionals, 

including doctors and nurses who have clinical and coding expertise, also work within the SIU. 

Finally, the data analysis team is comprised of individuals with IT or other computer-related 

backgrounds. The investigators are responsible for investigating assigned cases in order to detect 

fraudulent, abusive or wasteful activities/practices and to recover funds paid on such claims. Our 

programs at WellPoint also include collaborative efforts between our SIU and our contracted 

pharmacy benefit manager, Express Scripts, to identifY retail pharmacies cooperating with 

overprescribing or inappropriate prescription patterns and to exclude such pharmacies from our 

provider networks. 

Current Trends in Prescription Drug Diversion 

Today, some of the top fraud and abuse schemes we currently see in prescription drug 

coverage include: 

• The practice frequently referred to as doctor shopping, whereby individuals obtain 

prescriptions for frequently abused drugs from multiple prescribers and then fill 

them at different pharmacies. Oftentimes providers as well as pharmacies are 

involved in the scheme. 

• Bogus providers: these are providers that, although they may have National 

Provider Identifier numbers (which are usually stolen or purchased), do not 

actually perform services for real patients but bill insurers. 

• Pain management doctors overprescribing pain medications. 

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WellPoint currently has 160 investigations open involving Part D, which include drug 

seekers (doctor shoppers), identity theft, over-prescribers and bogus phannacy cases. WellPoint 

SIU refers every Part D case to the MEDIC, and WellPoint has the second highest number of 

referrals to the MEDIC nationwide. Our advanced analytics team at SIU target fraud and abuse 

including: 

-Identification of member drug seeking and doctor shopping 

-Geographic concerns - patients traveling long distances to prescribers and or phannacies 

-Regional/national prescription fraud and abuse trends 

For example, in 2011, WellPoint had a Part D member who obtained 77 controlled 

substances from 59 physicians filled at 51 phannacies. Physician specialties identified on the 

member's profile included emergency medicine, dentistry, dennatology, cardiology and internal 

medicine. This member drove to five outlying states to obtain and fill prescriptions and used 

eight different dentists for controlled pain medications. The member also visited 29 different 

emergency departments, averaging $800 per visit in her drug seeking efforts. While we referred 

the case to the MEDIC, we were unable to restrict the individual, as we currently do not have a 

restricted recipient program in place in Part D. 

WeliPoint's Successful Fraud Prevention Programs 

Our goal at WellPoint is to prevent health care fraud and abuse for the benefit of our 

members' health, as well as for the health care system as a whole. As such, WellPoint has 

developed a number of different types of programs to identify and prevent prescription drug 

fraud and abuse. Some of these include: 

• Controlled substance utilization monitoring (CSUM) program 

• Medicare and Medicaid restricted recipient program 

• Pre-pay provider review program 

• Bogus providers/phannacies 

• Predictive modeling program 

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Controlled Substance Utilization Monitoring (CSUM) Program 

Our nation has a significant problem with prescription narcotic drug abuse and patients 

have, at times, gamed the system by a practice known as doctor shopping, whereby individuals 

obtain prescriptions for frequently abused drugs from multiple prescribers and then fill them at 

different pharmacies. Often times, they make multiple emergency room visits in order to obtain 

multiple prescriptions for narcotic drugs. This results in increased costs, not just for unnecessary 

medications, but also for related emergency room visits, in-patient hospitals stays, and visits to 

physician offices and clinics - all based on phantom illnesses and injuries used simply to get a 

prescription. WellPoint has found that its affiliated health plans have paid $41 in related medical 

claims for every $1 paid in narcotic prescriptions for suspected doctor shopping members. 

Through a controlled substance utilization monitoring program, (CSUM), health insurers 

can aid in patient safety and identify those who are engaged in or contributing to prescription 

drug abuse. Our CSUM program in our commercial and Medicaid business identifies members 

who, within a three month period, visit three or more prescribing providers, visit three or more 

pharmacies, and have filled ten or more controlled substance prescriptions (narcotics, 

benzodiazepines and hypnotics) without a confirmed underlying medically necessary condition 

(such as cancer or multiple sclerosis) to justify numerous controlled substances. The goal is to 

prevent members who have exhibited a pattern of obtaining multiple prescriptions for controlled 

substances from different providers and multiple dispensations of these medications from 

continuing to obtain inappropriate amounts and dosages of drugs through their health care 

coverage. Members who are identified through this program are alerted to oversight of their 

Schedule II prescription drug activity and case managed. To date, the program has been very 

successful; for example it has helped saved millions of dollars in emergency department visits 

for drug-seeking behavior. There has not been significant abrasion, and in fact some members 

have found the program helpful in managing their treatment. 

Medicaid Restricted Recipient Program 

WellPoint has also implemented a restricted recipient program for our Medicaid plans in 

Indiana called "The Right Choices Program," and in Virginia called "RX Safe Choice," in which 

a member who has been identified at risk for abuse of controlled substances can be restricted to 

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the use of only one primary care physician, one retail pharmacy, and one hospital for any nonemergency care. Our case managers, who work specifically with both the Indiana and Virginia 

membership, work directly with providers and members regarding excessive controlled 

substance use. Once a member is placed in the program, the primary medical provider must 

approve all referral providers for the member. Efforts are made to connect members with 

behavioral health providers, case managers and community resources related to abuse and 

addictions. 

WellPoint supports giving CMS the authority to establish a restricted recipient program 

in Medicare Part D for those beneficiaries displaying a pattern of misutilization. To ensure 

members' safety, WellPoint believes that plans should not implement policies of denying a 

prescription fill, even in cases of suspected overutilization. WellPoint asks that CMS be 

responsible for taking any enforcement action once members suspected of misuse or 

overutilization has been identified by the plan sponsor. 

Provider Engagement in the Prescription Drug Trade 

Provider involvement in the prescription drug trade of narcotics and other expensive 

drugs is a serious problem in our country, in particular in the state of California. As noted in a 

November 11, 2012 Los Angeles Times article, "federal researchers reported that emergency 

room visits resulting from the non-medical use of opioid prescription drugs - often used in pain 

relief - more than doubled from 2004 through 2008. There were as many visits for those 

prescription medications as for illegal drugs."j Times reporters analyzed 3,733 prescription drugrelated deaths in four Southern California counties, revealing that just 71 doctors - one-tenth of 

one percent in those counties- had written prescriptions in 17 percent of such fatalities over six 

years. WellPoint SIU plays an instrumental part in identifying to California law enforcement 

agencies those providers who prescribe narcotics to individuals with no underlying medical 

conditions because it has access to phannacy infonnation and relevant medical records, enabling 

the identification of trends and outliers. We provide quarterly reports identifying the top 

prescribers in each California county and prepare individual reports where the recipients of the 

narcotics do not have underlying medical conditions. 

1 Los Angeles Times, November 11, 2012; "Legal Drugs, Legal Outcomes," by Scott Glover and Lisa Girion 

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Pain Management Doctors 

Operation Pillbox is an example of a recent, ongoing initiative by WellPoint's SIU to 

identify providers who engage in unsafe practices that defraud insurers. 

WellPoint's SIU launched Operation Pillbox in 2007, when our investigators noticed 

unusual prescribing patterns involving end-stage cancer drugs. Our investigators, working on 

behalf of our California health plan, detennined that a number of physicians were prescribing an 

unusually large quantity of a very strong narcotic meant to treat cancer patients with severe pain. 

Their research found that just 10 physicians prescribed more than a quarter of that drug in the 

entire state, with some patients receiving more than $200,000 worth of the medication, despite 

the lack of clinical evidence that the patients had cancer. 

The team then expanded their research to include other Schedule II narcotic drugs (such 

as oxycontin). They discovered that some physicians were prescribing these potentially 

addicting and life-threatening drugs with little or no medical justification. Believing that the 

suspect physicians may have been involved in the illegal sale and distribution of narcotics, 

WellPoint's investigators shared with local, state, and federal law enforcement authorities our 

infonnation regarding the physician'S background and prescribing patterns, the pharmacies 

involved, and the patients receiving the largest volume of the prescriptions. As a result, several 

of the physicians identified by Operation Pillbox have been arrested and criminally charged or 

stripped of their medical licenses. One of the physicians was linked to the overdose deaths of 

thirteen of his patients. 

Pre-Pay Provider Review Program 

Part of WellPoint's antifraud-program activities includes examining physician practice 

patterns, to detennine whether outlier physicians whose practices are different from the nonn are 

engaging in questionable behavior that are driving up costs and impacting patient safety. 

WellPoint investigators are able to identify aberrant provider practice patterns through data 

mining and analytics in which they look for outlier activities, such as significant dollar spikes in 

payments or cumulative dollar spikes in certain counties. WellPoint has implemented two such 

pre-pay provider review programs in which the most egregious billers who, after being educated 

and refusing to modify their billing behavior, are placed on "Flagged Pre-Payment Review." For 

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example, providers are identified as outliers if they show patterns of engaging in billing practices 

that are extremely aberrant compared to their specialty peers. "Upcoding" (coding a less 

intensive service as a more intensive procedure), billing an incorrect code to obtain coverage for 

a noncovered service, or billing at a particular facility to obtain extra reimbursement (e.g., billing 

a simple toenail clipping performed in an outpatient facility as debridement performed at an 

ambulatory surgery center) are examples of such outliers. 

If a provider shows a pattern of engaging in such outlier behavior, WellPoint 

investigators and Medical Directors intervene to communicate with the provider to educate and 

attempt to correct his or her behavior if appropriate. About 60 percent of providers change their 

practices within 90 days after receiving such communications. However, the 40 percent of 

providers that continue to engage in incorrect coding may be placed on pre-pay review. In that 

case, providers must bill with paper claims accompanied by medical records so that we can 

determine whether the procedures billed for are reflected in the records. 

Bogus ProviderslPharmacies and Identity Theft 

Bogus providers are those providers that, although they may have National Provider 

Identifier numbers (which are usually stolen or purchased), do not actually perform services for 

real patients. Instead, bogus providers steal or purchase patient identification numbers, establish 

a fake storefront office furnished with limited inventory, obtain a post office box, and proceed to 

bill insurers for fraudulent services and devices. Bogus providers are a significant problem in 

both commercial health insurance as well as in the Medicare Advantage and Medicare Part D 

programs.2 

WellPoint takes a multifaceted approach to identifying bogus providers and preventing 

their fraudulent billing. SIU's Provider Database team alerts investigators to the presence of 

new labs, pharmacies and durable medical equipment (DME) clinics, and performs a full 

background check as well as a drive-by of the provider's purported office space. Well Point also 

matches U.S. Post Office box numbers against our current claims to determine whether multiple 

bogus providers are using the same P.O. Box to receive payments (or whether the new provider 

has simply switched names and continues to fraudulently bill). To date, in the state of California 

2 Of note is that Section 6401 of the Affordable Care Act provides for a ninety-day period of enhanced oversight for 

the initial claims of DME suppliers where HHS suspects there may be a high risk of fraudulent practices. 

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alone, WellPoint has stopped over 239 bogus DME providers before they were able to submit 

fraudulent claims to the company. Additionally, during the past six months, WellPoint has 

identified and targeted 63 bogus pharmacies through collaboration with our pharmacy benefit 

manager, Express Scripts. Through our combined efforts we have been able to terminate 

contracts and stop payments to these bogus pharmacies resulting in savings of $2.1 million. 

A great example of the proactive work of the SIU in identifying bogus providers and also 

collaborating with our public partners at eMS and DOJ involves identifying and deterring health 

care fraud in the Medicare Advantage program. After a tip from one of our Medicare Advantage 

members who received an EOB for thousands of dollars of services he did not receive from an 

unknown provider, WellPoint commenced an investigation that led to the discovery of what 

appeared to be a large medical identity theft scheme perpetrated by an organized crime group. 

Further investigation of this organization resulted in discovery of bogus providers who were 

submitting fraudulent Medicare Advantage claims. In many cases, the perpetrators had stolen 

the provider identification numbers from local physicians, and utilized stolen Medicare 

Advantage identification members' numbers. Once this information was in hand, they began a 

deliberate and well-executed conspiracy to defraud our Medicare Advantage program. Our 

investigation revealed that claims paid from bogus providers were often for billings of a high 

volume of expensive infusion therapy (cancer and HIV -related) treatments for unknown 

conditions and from unknown providers. The claim profile of these providers exhibited the 

characteristics of having invalid contact information (but including identification information 

from legitimate doctors to make them appear genuine), as well as irregular banking methods to 

cash payment checks. 

Our SIU worked closely with claims operations areas to develop a proactive program to 

assist in identifying any provider fitting the same claim and provider profile as the bogus 

providers. The proactive process involves identifying any previously unknown provider billing 

the suspicious high dollar infusion therapy. These providers and their claims are immediately 

pended in the system and submitted to the SIU for review. Additionally, with respect to 

providers already in the claims systems with the same billing and provider profile, an edit 

process was inserted in the claims system to pend and review claims similar to those used by the 

bogus providers. 

As a result of the investigation, in 2011 SIU identified 36 bogus providers who engaged 

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in this scheme. Due to the proactive work of SIU, $33 million dollars offraudulent claims were 

stopped during the claims adjudication process, or newly issued checks to the perpetrators were 

stopped before they were negotiated. The total amount in savings to the Medicare Advantage 

program was $33,748,292.94. 

Predictive Modeling 

WellPoint has recently contracted with a vendor to provide an automated solution to 

enable WellPoint to continuously monitor medical (professional claims on CMS Forms 1500) 

claims across the company in a post-payment or future pre-payment environment. The initial 

rollout focuses on deploying the solution in the post-payment environment. WellPoint initially 

rolled out the program in Georgia, with the intent to implement it enterprise-wide in 2013. 

The program uses advanced neural network technology from FIC03 to identifY 

previously unknown and emerging fraud and abuse provider/member schemes. FICO-based 

analytics score suspect claims on a scale of 1-1 000 and identify aberrant provider/member 

behaviors. Suspect providers and claims are reviewed by a triage unit and the SIU to identify 

potential fraud, waste or abuse, and depending on the type of findings are then assigned to the 

investigative unit to investigate, prevent and stop ongoing fraud and abuse. 

Since we began using this tool, WellPoint's SIU has opened 200 investigations and has achieved 

$27 million in projected savings to date. For example, the program has revealed patients with 

consecutive days of anesthesia, which is not medically likely, as well as lab testing for cardiac 

risk or food sensitivities where labs were billing for hundreds of units of antigens. The program 

has also identified certain weaknesses in our systems and procedures, which we then work 

quickly to strengthen. In 2013, WellPoint will save over $13 million alone by placing a system 

edit for urine drug testing abuse by labs, one of the collateral abuses spawned by prescription 

drug abuse in the U.S. 

, FICO is the acronym for Fair Isaac Corporation, which provides analytics and decision making services to assist 

financial services organizations in making complex, high volume deciSions 

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Recommendations: 

Based on our experience in combating prescription fraud and abuse, WellPoint offers the 

following recommendations to enhance future efforts throughout all sectors of health care: 

• Medicare Restricted Recipient Program 

WellPoint supports giving CMS the authority to establish a restricted recipient program 

in Medicare Part D for those beneficiaries displaying a pattern ofmisutilization. WellPoint 

systematically reports beneficiary-specific concerns- based on objective, standardized 

metrics-to CMS or to Medicare Drug Integrity Contractors (MEDIC) for appropriate action 

against the individual beneficiary. To ensure members' safety, WellPoint believes that plans 

should not implement policies of denying a prescription fill even in cases of suspected 

overutilization. From a health plan perspective, we would want to work with the prescribing 

physician and/or refer the case to CMS or its delegate. WellPoint asks that CMS be responsible 

for taking any enforcement action once members suspected of misuse or overutilization have 

been identified by the plan sponsor. Once sufficient due diligence has been conducted by CMS 

or its delegate to demonstrate abuse, or upon recommendation of the provider, the member can 

be placed in the restricted recipient program which the plan sponsors manage pursuant to clear 

regulatory protocols. 

• Dual Eligible Beneficiaries 

Through our experience in providing health care coverage through both our Medicaid 

state-sponsored programs and Federal programs, we have observed that a large portion of the 

opioid and controlled substance abuses in the Part D program occur among the dual eligible 

population - beneficiaries eligible for both Medicare and Medicaid and often under 65 years of 

age. In calendar year 2012 alone, WellPoint's SIU unit tracked 69 investigations of Medicare 

Part D beneficiaries under the age of 65. Under current law, dual-eligible beneficiaries are 

allowed to change plans on a month-to-month basis, which permits drug seekers to switch 

programs frequently in order to avoid detection and escape program edits or substance abuse 

programs. 

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WellPoint recommends that dual eligible beneficiaries with evidence of drug-seeking 

behavior should be locked into one managed care plan, rather than continue to be allowed to 

switch plans on a monthly basis to evade detection. 

• Improved Partnerships 

WellPoint supports better coordination and cooperation among CMS, DOJ, and all 

stakeholders. Right now, there is little collaboration between the agencies and the health plans 

that oftentimes have the information, experience and expertise necessary for preventing and 

fighting fraud and abuse. In order to be truly effective throughout the health care system, both 

public and private sectors should be working together to share successful anti-fraud practices, 

effective methodologies and information about ongoing fraud investigations. For example, while 

health plans currently share information with the MEDlC, we are rarely informed of the ultimate 

result, and information collected by the agency is rarely shared with the private payers. Another 

example is that CMS does not share information on revoked Medicare providers with private 

payers. 

However, we are optimistic by the creation last year of the Healthcare Fraud Prevention 

Partnership, a voluntary partnership composed of both the public and private sector for the 

purposes of reducing the prevalence of health care fraud. WellPoint is an active participant, and I 

serve on the Data Analysis and Review Committee. It is our hope that the work of the 

partnership will lead to successful public/private collaboration in the prevention and detection of 

health care fraud. 

• Enconrage Fraud Prevention by Private Health Insurers and in the Medicare 

Advantage Program 

Experience has proven in both private and public program fraud investigations that fraud 

prevention is much more effective and cost-effective than pursuing "pay and chase" type fraud 

investigations. "Pay and chase" investigations recoup only about 20 cents on the dollar, while 

fraud prevention investigations result in dollar-for-dollar savings by avoiding improper 

payments. Moreover, fraud prevention investigations often remove fraudulent and harmful 

providers from the healthcare system before they can do more damage to public and private 

healthcare programs and their members. In recent years the Department of Justice and HHS have 

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adopted successful fraud prevention tactics. The federal government should do everything it can 

to encourage fraud prevention for private health insurers, as well. 

One way this can be done is to permit health insurers to lift the current restriction on 

health insurers' fraud programs in the Medical Loss Ratio (MLR) calculation, which appears in 

the MLR regulations for both commercial health insurers4 as well as Medicare Advantage.s 

For both public and private health care programs subject to the MLR, expenses for health 

insurer anti-fraud and abuse programs should be included as "activities that improve health care 

quality" in the MLR calculation, since they reduce waste in the health care system, reduce the 

cost of health care, and enhance patient safety by helping identify and remove providers and 

individuals engaging in unsafe and fraudulent practices from the health care system. 

Currently the MLR final regulations for both commercial health insurance and Medicare 

Advantage merely give insurers a limited credit - up to the amount of fraud recoveries - for 

fraud prevention activities. In essence, this means that insurers will have to include as 

administrative expenses their largest portion of antifraud expenses -- those dedicated to fraud 

prevention. It is truly puzzling that at a time when the federal government is accelerating its 

efforts to prevent fraud in Medicare and Medicaid it has simultaneously issued regulations that 

will serve to discourage health insurers' fraud prevention efforts in the private and public sectors. 

Ironically, eliminating antifraud programs will tend to increase MLR percentages because claims 

will be higher, but an increased MLR will be at the expense of patient safety, quality of care, and 

controlling health care costs, which are the very goals of the Affordable Care Act. 

If health insurers are discouraged from keeping their anti-fraud programs in place at the 

same time that anti-fraud efforts are increasing in the traditional Medicare program, federal law 

enforcement will lose a valuable source of information and tips about providers and recipients 

who may also be engaging in defrauding public programs. Additionally, restricting the expenses 

that Medicare Advantage plans can incur for fraud prevention activities may foster fraud and 

abuse in that program. 

4 See 45 C.F.R. lS8.140(b)(2)(iv). 

5 See 42 C.F.R. 422.2420(b)(2)(ix). 

*** 

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In conclusion, I would like to thank the Committee for the opportunity to testify today on 

behalf of Well Point on this critical issue, and pledge our support in any efforts to make the health 

care system financially viable and safer for our members. 

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WWW.HCPANET.ORG 

PHARMACISTS ASSOCIATION 

Statement of the National Commnnity Pharmacists Association (NCPA) 

United States Senate Committee on Homeland Security and Governmental Affairs 

Hearing on Curbing Prescription Drug Abuse in Medicare 

June 24, 2013 

Chairman Carper, Ranking Member Coburn, and Members of the Committee: 

The National Community Pharmacists Association (NCPA) welcomes and appreciates the opportunity 

to provide feedback and suggestions regarding efforts to combat fraud, waste, and abuse in the Medicare 

Part D program. NCPA represents the interests of America's community pharmacists, including the 

owners of more than 23,000 independent community pharmacies, pharmacy franchises, and chains. 

Together they represent a $93 billion health-care marketplace, have more than 315,000 employees 

including 62,400 pharmacists, and dispense over 41 % of all retail prescriptions. NCPA members are a 

primary access point for prescription medications for millions of Part C and D beneficiaries and NCPA 

members comprise a critical piece of the Part C and D prescription drug distribution system. 

Community Pharmacy's Commitment to Figbting Fraud, Waste, and Abuse 

NCPA strongly believes in the mission to eliminate fraud, waste and abuse in Medicare in order to 

bolster the integrity of the program and maximize the benefits provided to beneficiaries. Our members 

strive to do their part to help ensure these goals. NCPA and independent community pharmacists are 

committed to fighting fraud, waste and abuse within the Medicare prescription drug program, and offer 

the following recommendations: 

Greater transparency and incentive realignment needed to combat waste and identify true fraud 

Pharmacy benefit managers (PBMs) are corporate middlemen that contract with Part D plan sponsors to 

provide prescription drug coverage to tens of millions of seniors, individuals with disabilities, and low 

income individuals. While they playa large role in the delivery of health care to beneficiaries, they 

continue to operate in the shadows and their activities remain largely unregulated. As the largest payer 

of health care, the federal government must have a better understanding of their business practices, 

because the lack of transparency in PBM activities creates program vulnerability. 

PBMs create potential for greater waste 

The misalignment of payment incentives and profit motives of PBMs, who also own and operate their 

own mail order facilities, only serve to encourage greater utilization of mail order and the practice of 

automatic shipment of refills. An example is within the current structure of the Medicare star quality 

ratings for plans. One incentive for plans to improve their quality ratings is related to a medication 

adherence measure, which NCPA has contended is based solely on prescription claims data with no tie 

or correlation to outcomes. Prescription claims data is based on how many total days of therapy a patient 

THE VOICE OF THE COMMUNITY PHARMACIST 

100 Daingerfield Road 

Alexandria, VA 22314-2888 

(703)683-8200 PHON. 

(703) 683·3619 'AX 
98 

actually has medication on hand, not whether it's been taken appropriately. We continue to reiterate our 

concerns that simply shipping the product every 30 or 90 days without proper clinical assessment of the 

patient for therapeutic appropriateness is not true adherence and in fact, can generate more waste. If 

ratings continue to be calculated on how many fills a patient receives without factoring true clinical 

improvement, plan sponsors will continue to be motivated to ensure that patients are always shipped 

refills, whether or not the medication was needed or wanted. A consequence of this is seniors can find 

themselves advancing through the Part D benefit phases prematurely if they truly did not need those 

extra refills but were billed anyway. 

Furthermore, Medicare may be overbilled when medications are automatically filled without prior 

consent from the patient. NCP A supports the recent establishment by CMS of clear policies and 

parameters surrounding auto-ship refill programs in the Part D program. In the 2014 Call Letter issued 

by CMS to plan sponsors, the Agency stated that it has become aware that while pharmacies may obtain 

an initial beneficiary consent to provide automatic refills, the pharmacies may not have verified that the 

beneficiary needs the medication before each subsequent refill is delivered. In addition, CMS also has 

become aware that some mail order pharmacies are automatically delivering new prescriptions that a 

beneficiary's prescriber has phoned in or e-prescribed despite the fact that the patient may not want the 

prescription filled at that time or via mail order. CMS concluded that these automatic fill practices, "are 

potentially generating significant waste and unnecessary additional costs for beneficiaries and the Part D 

program overall." Therefore, CMS has advised that Part D sponsors should require their network retail 

and mail pharmacies to obtain patient consent to prior to the delivery of each prescription. 

Abusive audit practices deterring from true patient care and fraud detection 

Community pharmacists understand and support legitimate auditing practices, and while Part D 

pharmacy audits are necessary, drug plan intermediaries such as PBMs are abusing this process by 

singling out expensive drugs and using clerical, typographical and other trivial errors to recoup from 

pharmacies significant amounts that may not be returned to the Medicare program. NCPA appreciates 

the steps that Medicare officials took in the final Call Letter to address concerns about auditing issues 

that can negatively impact the program's cost and quality of care. Within the 2014 Call Letter, CMS 

admits that, "[tJhe increasing incidence of these adjustments for 'routine clerical errors' rather than 

incorrect payment amounts (financial errors) may be related to the incentives in contingency 

reimbursement arrangements with claim audit vendors." The Call Letter goes further to state, "[w]e are 

concerned that the growing practice of post-audit total claim recoupments from pharmacies is distorting 

Part D payment, as well as compromising Part D data integrity and impairing our ability to oversee the 

program." 

Not only does recoupment by PBMs for clerical errors take up valuable resources that should be targeted 

at identifying true fraud, waste, and abuse, it may also distract CMS from adequately providing 

oversight to the program which could compromise Part D data integrity. NCPA strongly encourages the 

Committee to work with the Agency and appropriate stakeholders to target true fraud, waste and abuse 

and to discourage practices that only serve to identify clerical errors and recoup large amounts from 

pharmacies. Furthermore, NCPA supports the bipartisan legislation introduced in the Senate which 

would achieve a more balanced business relationship between PBMs and community pharmacies, 

thereby allowing pharmacists to continue putting patients first in health care. The Medicare Prescription 

Drug Program Integrity and Transparency Act (S. 867) would focus pharmacy audits on uncovering 

actual fraud and abuse, bring transparency to generic drug reimbursement rates and give Medicare 

beneficiaries additional privacy and other protections. 

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Ensuring program integrity is a shared responsibility 

NCP A applauds the Committee for taking a hard look at the vulnerabilities that exist within the 

Medicare prescription drug program that potentially lead to waste and fraud, and we strongly support 

efforts to eliminate such abuse within the program. However, we remain concerned that some of the 

efforts by the Agency and private payers to reduce fraud are overly broad, abusive, and inadvertently 

label legitimately operating pharmacies as bad actors. There needs to be a collective approach to 

controlling abuse and diversion that involves every stakeholder in the supply chain: manufacturer, 

wholesaler, prescriber, payer, pharmacist, and patient. 

While we believe that all stakeholders should remain laser-focused on routing out fraud, waste and 

abuse, recent efforts to crack down on fraudulent behaviors have taken a broad approach and do not 

hone in on truly abusive practices. Strictly examining prescription drug event (PDE) records without 

placing some context around the claims data is like judging a book by its cover, which potentially places 

legitimately operating pharmacies in the spotlight for further scrutiny. 

For example, independent pharmacies serve a disproportionately high number of long-term care and 

other patients who are prescribed more medications than the average Medicare beneficiary. In addition, 

independent pharmacies are often situated in underserved, rural areas with few physicians nearby and 

therefore may bill for a higher than average number of prescriptions per prescriber. Conversely, many 

independents are also located in urban areas near large teaching hospitals or cancer clinics where 

physicians prescribe a disproportionate share of controlled substances, including schedule II and III 

medications. Community pharmacists also serve diverse patient popUlations with specialized needs, 

which may necessitate the compounding of medications. Each of these examples are likely to result in a 

negative assessment by CMS or others of the pharmacies' risk and could inadvertently single out certain 

community pharmacies based on wholly unwarranted factors. 

As one of the most accessible and trusted health care providers, community pharmacists recognize the 

importance of addressing the serious and growing problem of prescription drug diversion and abuse. 

NCPA is encouraged to see the that the Office of National Drug Control Policy (ONDCP) has made the 

issue of prescription drug abuse a top priority and believes that community pharmacists are wellpositioned to respond to the action items laid out in the Administration's Prescription Drug Abuse 

Prevention Plan, particularly in the areas of education, tracking and monitoring, and proper disposal. 

We strongly believe in tactics that focus on prevention and proactive monitoring. Examples include: 

greater provider education, appropriate prescribing, and requiring all Part D prescribers to be validated 

as Medicare providers. In addition, with appropriate safeguards, we could support the concept of a 

"lock-in" program limiting certain patients to a specific pharmacy for controlled substances. However, 

such a system must be a level playing field for independent community pharmacies and not one that 

inadvertently incentivizes patients to use a national chain pharmacy, for example. Patients should not be 

locked against their will into a pharmacy they don't want to use or into mail order pharmacies, which 

typically ship 90-day supplies that are particularly inappropriate for controlled substances. 

Given the climate of tightened resources, what's needed in terms of fraud protection efforts is for 

Medicare, payers, and providers to work smarter and more efficiently. We believe that all relevant 

stakeholders should work collectively, with timely feedback and information sharing in order to 

effectively address these issues. NCP A stands ready to work closely with the Committee, members of 

Congress, CMS, and other payer and provider groups on a set of sensible solutions that truly address 

fraudulent behavior, while preserving patient access to much needed health care products and services. 

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Of/ice ofthl.: Assistant Attorney General 

The Honorable Thomas R. Carper 

Chairman 

U.S. Department of .Justice 

Office of Legislative Affairs 

Washington. D.C 205311 

December 12, 2013 

Commillec on Homeland Security and Governmental Affairs 

United Stales Senate 

Washington. D.C. 205 J 0 

Dear Mr. Chairman: 

Enclosed please find responses to questions for the record arising from the appearance of 

Joseph T. Rannazzisi, Deputy Assistant Administrator. Office of Diversion Control, Drug 

Enforcement Administration, before thc Committee on June 24. 2013. at a hearing entitled 

"Curbing Prescription Drug Abuse in Medicare." We hope that this intormation is of assistance 

to the Committee. 

Please do not hesitate to contact this ot1ice if we may be of additional assistance 

regarding this or any other matter. The Office of Management and Budget has advised us that 

there is no objection to submission of this letter from the perspective oflhe Administration's 

program. 

Enclosure 

cc: The Honorable Tom Coburn 

Vice Chairman 

Sincerely, 

~).~y.{{ Peter J. Kadzik 

Principal Deputy Assistant Attorney General 
101 

Questions for the Record 

Joseph T. Rannazzisi 

Deputy Assistant Administrator 

Office of Diversion Control 

Drug Enforcement Administration 

V.S. IJepartment of Justice 

Committee on Homeland Security and Governmental Affairs 

United States Senate 

"Curbing Prescription Drug Abuse in Medicare" 

June 24, 2013 

Questions Posed by Senator Tom Coburn 

In your testimony, you said there are more than 1.4 million registrants in the DEA 

database. You also said DEA maintains over 2 million registration records in a database 

that includes historical and current regulatory action(s) taken against a registrant. 

1. Does CMS, the MEDIC, or sponsors have access to this data'! 

Response: 

DEA currently provides access to the registrant database (excluding certain Personally 

Identifiable Information (PII) relating to individual registrants) to numerous regulatory and law 

enforcement agencies in furtherance of their respective missions in 43 states and trust territories 

and 10 the Office of Inspector General at the Department of Health and Human Services. While 

CMS. the MEDIC. or the sponsors do not have access to the registrant database. DEA makes the 

database. excluding Pl!, available to Federal and state regulatory or law enforcement agencies 

upon request. In addition. a version of the database is commercially available to the public for 

purchase on the U.S. Department of Commerce National Technical Information Service (NTIS) 

website. 

In your testimony. you said DEA provides lin elc~trol1ic means by which registrants can 

check the validity of another registrant's I>EA registration number free of charge. DEA 

also provides access to state agencies that have a responsibility to investigate health care 

fraud. I>EA provides daily access to the registrant datahase to 41 states, Guam, and I).c., 

which have requested the data. 

2. Docs CMS, the MEDIC, or sponsors have access to this data? 

Response: 

Access to the dala is available 10 CMS upon request; however. the online validation feature is nol 

presently available to eMS, Ihe MEDIC, or 10 the sponsors. You must be a DBA registrant to 

have access 10 Ihis feature. 
102 

Questions Posed by Senator Mark L. Pryor 

I understand that the Drug Enforcement Administration (DEA) released a proposed rule in 

December 2012 that would implement the Securc and Responsible Drug Disposal Act of 

20 I O. I have hcard concerns about the approach taken in that rule for the disposal of 

controlled substances in long term care facilities. The concerns focus on a lack of 

flexibility, diversion opportunities, a lack of harmonization with anti-kickback laws and 

other federal and state regulations, stockpiling risks and on the costs of pharmacy-operated 

disposal receptacles. Can you provide an update on the status of that proposed DEA rule 

on the 2010 drug disposal law? 

3a. Is the DEA aware of those concerns? 

3b. If so, how is the I>RA planning to address those concerns? 

Response: 

On December 21.2012. DEA published in the Federal Register a Notice of Proposed Rulemaking 

(NPRM) on the disposal of controlled substances. This NPRM proposes requirements to govern 

the secure disposal of controlled substances by both DEA registrants and ultimate users. These 

regulations would implement the Secure and Responsible Drug Disposal Aet of2010 (Pub. L. 

I I 1-273) by expanding the options available to collect controlled substances from ultimate users 

for purposes of disposal to include: take-back events. mail-back programs. and collection 

receptacles. The NPRM comment period closed on February 19.20 I 3. Since then. DEA has 

been ean:fully reviewing the almost 200 comments received to the NPRM from a wide range of 

interested persons. DEA is committed to addressing in the Final Rule all of the issues raised in 

the comments to the NPRM. including any concerns raised by the long term care industry and our 

Federal partners. 

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103 

Post-Hearing Questions for the Record 

Submitted to Jonathan Blum 

"Curbing Prescription Drug Abuse in Medicare" 

June 24, 2013 

Senator Claire McCaskill 

1. The Inspector General said that a major barrier to the MEDIC's use of 

proactive methods is that it doesn't have access to patient and provider 

information. Why don't the MEDICs have access to the information they need 

to conduct proper oversight? 

2. What are you doing to enhance the ability of the MEDICs to access the data they 

need? 

Answer to Ql and Q2: CMS agrees with the OIG that in order to be effective the 

MEDIC must have access to relevant patient and provider information to carry out its 

work as a CMS Part D fraud contractor. Although the MEDIC has had access to Part D 

prescription drug event records for some time now, its access to other CMS data and 

systems was limited. As a result, recently, CMS expanded the MEDIC's access to more 

information and systems to assist its oversight functions. Since 2012, the MEDIC has 

been granted access to the Health Plan Management System modules, Provider 

Enrollment and Chain Ownership System (PECOS), and Statistical Analysis System 

Enterprise Business Intelligence, which allows for the manipulation oflarge amounts of 

data in a short amount of time. In addition, CMS has worked to increase communication 

and data sharing between the MEDIC and the Zone Program Integrity 

Contractors (ZPICs). 

Pursuant to an OIG recommendation and concerns raised by the MEDIC, CMS is 

considering regulatory changes that would give the MEDIC greater access to pharmacy 

benefit managers (PBMs) and pharmacies and prescribers' records. Such access would 

give the MEDIC the ability to more quickly investigate its cases and remove the burden 

associated with going through the Part D plan to access relevant documentation that may 

be housed with a pharmacy or PBM. 

3. The MEDIC contractor is required to use proactive methods, including data 

mining and analysis, as well as external sources (e.g., leads from beneficiaries, 

law enforcement agencies, and Medicare Part C and D plan sponsors) to identify 

potential fraud and abuse. However, a 2009 report by the Department of Health 

and Human Services Office of the Inspector General found that only 4% of the 

MEDIC's investigations were initiated using proactive methods. That number 

has increased as of the HHS-OIG's January 2013 report, but only to 10%. Has 

the MEDIC been earning award fees despite its failure to conduct proactive 
104 

reviews? Why have you failed to solve problems that the Inspector General first 

found four years ago? 

Answer: Since the end of the OIG's review, CMS has refocused the goals of the current 

MEDIC's responsibilities. We are requiring the MEDIC to develop a new set of 

deliverables that include a monthly vulnerability report and data analysis plan report, 

which lists the project name, description, and status of each proactive data analysis study 

it conducts. 

CMS agrees with the OIG that proactive investigations are important in the overall 

identification and prevention of fraudulent activity and we have taken additional steps to 

ensure the MEDIC is doing more proactive data analysis as part of its Statement of Work. 

Under the direction of CMS, the MEDIC has increased the number of proactive data 

analyses projects it completes since the end of the OIG's review. The structure of the 

MEDIC contract does not include award fees; as such, CMS has not paid the MEDIC for 

any additional services beyond what is included in their existing Statement of Work and 

Task Orders. 

It is worthwhile to mention the MEDIC performs a variety of tasks for CMS in addition 

to proactive data analysis projects. The other work areas of the MEDIC include: 

(1) investigating and developing all complaints; (2) providing referrals; (3) conducting 

and assisting investigations; (4) completing other forms of data analysis; (5) offering 

CMS support; (6) providing the OIG and other law enforcement Subject Matter Experts 

for trial; (7) performing impact calculations; (8) conducting Regional Office 

education/presentations; (9) collaborating and educating Part D sponsors on identifying 

potentially-fraudulent schemes; and (10) maintaining a dedicated toll-free Part D fraud, 

waste, and abuse hotline. CMS evaluates the MEDIC on all the functions it is 

responsible for carrying out under the contract. 

4. The OIG also recently found that Medicare paid millions of dollars for 

prescriptions from unauthorized prescribers, including massage therapists, 

athletic trainers, dental hygienists, occupational therapists, and even home 

repair contractors. These should be among the easiest things to find and stop 

prescriptions being written by people that have no business writing 

prescriptions. This seems like relatively low-hanging fruit as far as rooting out 

Medicare fraud goes. Was the MEDIC aware of these issues? Do they get the 

credit for bringing them to your attention, or did the OIG find them first? 

Answer: While the MEDIC was aware and had been investigating (or had referred to law 

enforcement) some instances of unauthorized prescribers, the OIG report did bring 

additional unauthorized prescribers to our attention. CMS shares your concern about any 

instance in which a prescription could have been written by a non-authorized prescriber, 

and unfortunately, given the nature of pharmacy claims processing, it is not always easy 

to identify at point-of-sale if an unauthorized prescriber wrote a prescription. We are 

exploring additional credentialing options that will help us more easily identify 

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unauthorized prescribers and, in the meantime, CMS has initiated a comprehensive 

investigation of the OIG findings. We will determine if they are attributable to an 

administrative error, such as the data accuracy of the taxonomy code (the type, 

classification, and/or specialization of health care providers) selected by the prescriber in 

the National Plan and Provider Enumeration System (NPPES) or are truly unauthorized 

Part D prescriptions. We are examining a sample of "unauthorized" prescriptions 

presented at the pharmacy to determine whether the prescription was actually written by 

an unauthorized prescriber, a claims data entry error that resulted in the appearance of an 

unauthorized prescriber (for instance due to the incorrect selection of the NPI number), or 

an incorrect taxonomy designation in the National Plan and Provider Enumeration 

System (NPPES) associated with the authorized prescriber. In the cases where we 

identify an incorrect taxonomy designation, we will reach out to the authorized prescriber 

and encourage him or her to correct the taxonomy information. Our initial findings from 

this investigation should be available by early 2014. 

5. Part D sponsors are required to have a comprehensive plan to detect, correct 

and prevent waste, fraud and abuse. Do all the Part D sponsors even have a 

plan? Has anyone ever checked? 

Answer: Yes, Medicare regulations require that all Part D sponsors have a 

comprehensive program in place to prevent, detect and correct fraud, waste, and abuse. 

Since 2010, CMS has conducted on-site audits of Part D sponsors' Compliance Programs 

to confirm that Part D sponsors have established and implemented effective Compliance 

Programs to prevent, detect and correct fraud, waste, and abuse. These audits include 

extensive review of documentation and systems, physical inspections of Part D sponsor 

facilities to observe non-compliance or potential fraud, waste, and abuse, and interviews 

with CEOs, Board Members, Compliance Officers, senior management, and front line 

staff. CMS holds the Part D sponsor's senior leadership (including the Board) 

accountable for ensuring the implementation of effective Compliance Programs. 

In addition, on July 27,2012, CMS issued revised Compliance Program Guidelines to all 

Part 0 sponsors, through manual guidance (Chapter 9 of the Medicare Prescription Drug 

Benefit Manual), to assist Part D sponsors in the establishment and implementation of 

effective Compliance Programs to prevent, detect and correct Medicare non-compliance 

and potential fraud, waste, and abuse. 

6. Sponsors are not required to share information that they gather on fraud and 

abuse schemes with the MEDIC, nor, according to the IG, are they doing so. In 

fact, the IG states in their testimony that some plan sponsors did not identify a 

single potential fraud and abuse incident, and that only a small number of 

sponsors are reporting the majority of the incidents that ever get reported. Why 

aren't the Part D sponsors required to report these incidents? 

Answer: As our regulations are currently drafted, the reporting of fraud, waste and abuse 

by Part D plans is voluntary. As we continue our education, outreach and oversight 

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efforts, eMS will monitor which plans are reporting fraud, waste, and abuse and will 

consider a requirement that Part D sponsors report instances of fraud, waste, and abuse. 

eMS is aware that certain Plan sponsors report more fraud and abuse than others, and 

through guidance and education, eMS will continue to encourage Part D sponsors to 

voluntarily refer potential fraud, waste, and abuse incidents that may warrant further 

investigation. 

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Senator Tom Coburn 

1. You said in your testimony that "prescription drug abuse is the Nation's fastestgrowing drug problem," to the point where CDC calls it an "epidemic." As you 

know, prescription drug "lock in" program is common policy among private 

insurance plans and Medicaid, which effectively restricts Medicare beneficiaries 

to a single physician or pharmacy if they engage in doctor shopping to amass 

large quantities of prescription pain medications from multiple physicians and 

pharmacies. 

a. Please outline CMS's preferred parameters for a modification of the 

statute underpinning Part D to allow for plan sponsors to "lock-in" 

beneficiaries into one pharmacy if they are at risk of abusing drugs? 

Answer: Any statutory change should provide the Secretary with authority to ensure 

consistent implementation of such a program in a manner that does not impair 

beneficiaries' access to medically necessary drugs. The CMS Office of Legislation is 

available to provide your staff with more detailed technical assistance in developing any 

such legislation. 

In addition, state Prescription Drug Monitoring Programs, which exist in 49 states, allow 

prescribers to check prescriptions, which helps to safeguard against patient doctorshopping. 

2. On page 57 of the statement of work for the Medicare Drug Integrity Contractor 

(MEDIC), CMS says: "the MEDIC's ability to make use of available data and 

apply innovative analytical methodologies is critical to the success of a benefit 

integrity program." However, a January 2013 OIG report that found while the 

MEDIC has an annual budget of approximately $14 million, only 21 referrals to 

law enforcement were discovered through proactive means! CMS has a 

responsibility to taxpayers and patients to do better. 

a. What specific steps will you take to get better value from the MEDIC 

contract? 

Answer: Since the end of the OIG's review, CMS has refocused the goals of the current 

MEDIC's responsibilities to address the identified issues. We are requiring the MEDIC 

to develop a new set of deliverables that will help improve their performance and ensure 

they are meeting their responsibilities. The MEDIC deliverables include a monthly report 

which tracks total complaints, investigations, requests for information, outreach 

activities, proactive data analysis, and law enforcement referrals completed for Medicare 

Parts C and D programs. The monthly report also provides an overview of audits, data 

analysis, and investigative success stories. The MEDIC submits a monthly vulnerability 

report and data analysis plan report, which lists the project name, description, and status 

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of each proactive data analysis study it conducts. CMS is using these reports to ensure 

the MEDIC is being more proactive. 

In addition, while the importance of referrals to law enforcement is clear, it should be 

noted that the MEDIC provides additional value beyond proactive analysis through 

overseeing efforts to detect, prevent and educate relevant parties on fraud, waste, and 

abuse, including by: (l) investigating and developing all complaints; (2) providing 

referrals; (3) conducting and assisting investigations; (4) completing other forms of data 

analysis; (5) offering CMS support; (6) providing the OIG and law enforcement with 

SUbject Matter Experts for trial; (7) conducting impact calculations; (8) providing 

regional office education/presentations for the entire Medicare Part C and Part D 

programs; and (9) maintaining a dedicated toll-free Part D fraud, waste and abuse hotline. 

b. What is your timeframe for doing so? 

Answer: CMS has already refocused the MEDIC contract to address the OIG's 

recommendations; however, CMS will continue to review the goals, workload, 

deliverables and responsibilities of the MEDIC to evaluate the value the MEDIC brings 

to detecting, investigating and preventing fraud waste and abuse within Medicare Part C 

and Part D programs. 

c. What assurances can you give this committee that CMS will do a better 

job of oversight? 

Answer: As evidenced by my testimony, CMS is committed to addressing the serious 

issues raised by the Committee, HHS OIG and the GAO, through a number of reforms, 

including more rigorous oversight of the MEDIC contractor, proactive data analysis and 

data sharing with the Part D Plan sponsors, the implementation of a beneficiary opioid 

overutilization monitoring program, improved identification of prescribers, and the 

consideration of new regulations that would strengthen our ability to determine which 

physicians may prescribe drugs to Medicare beneficiaries. We are available to discuss our 

ongoing progress in this area. 

3. In CMS's program manual, the agency recommends Part D sponsors use Drug 

Utilization Reviews to identify the number of prescriptions filled by an 

individual enrollee. Yet, we have seen the OIG's review and ProPublica's review 

of the data. 

a. How regularly does CMS or its MEDIC contractor conduct Drug 

Utilization Reviews? 

Answer: Each Part D sponsor is required to establish drug utilization management 

program and quality assurance measures and systems. CMS reviews and approves Part D 

sponsors' proposed utilization management edits (prior authorization, step therapy, and 

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quantity limits) prior to the start of each benefit year; other retrospective drug utilization 

reviews (DUR) protocols can be reviewed by CMS as part of our Part D sponsor audits. 

CMS also has established a monitoring program to measure Part D sponsors' compliance 

to our opioid overutilization DUR policy. On a quarterly basis, Part D sponsors confirm 

that case management or action has been taken on any beneficiary enrolled in their plan 

that meet CMS' targeting criteria and report to us the status of case management 

investigations. CMS will take compliance actions against any Part D sponsor not 

meeting our opioid overutilization standards. 

b. Why doesn't CMS or the MEDIC do more, when CMS is the one 

administering the program? 

Answer: I agree that CMS must take additional steps to enable Part D sponsors to 

implement more effective controls. The MEDIC has new performance deliverables 

required under their contract. Specifically, the opioid overutilization DUR standard is 

one example of a step CMS has taken recently to target fraud, waste, and abuse using 

DUR protocols, and we are continuing to explore additional programs to implement. 

Because the Part D sponsors have the real-time pharmacy claims information necessary 

to implement controls at the point-of-sale, CMS developed a methodology to identify 

potential opioid overutilizers based on drug claims data through clinical thresholds 

(excessive cumulative dose over an extended period oftime) and prescription patterns 

(multiple prescribers and pharmacies) that should trigger case management by Part D 

sponsors. The methodology excludes as early as possible those beneficiaries who have 

legitimate diagnoses that may warrant high opioid use (e.g., cancer patients or others who 

need palliative care), or who are borderline cases. Our methodology identified 

approximately 22,000 Medicare beneficiaries that met our targeting criteria. 

Although we are early in the reporting by Part D sponsors, we have determined that our 

case management process has been able to distinguish between beneficiaries who warrant 

a reduction in opioid dosing and those who have no medical need for opioids. These 

beneficiaries are subject to opioid overutilization management by the Part D sponsor. 

CMS, through its Final Calendar Year 2013 Call Letter and subsequent guidance, 

outlined an approach to reduce potential opioid overutilization in the Part D program. 

Under this approach, Part D plans ensure safe dosages are dispensed through the 

improved use of concurrent claim edits and formulary utilization management design. 

CMS' guidance clarified that Part D sponsors should clinically analyze cases for unsafe 

cumulative dosing that DUR programing has identified through patterns that suggest 

potential overutilization of drugs. 

Additionally, CMS has undertaken a communication and educational campaign about 

medication overutilization, particularly opioids, for physicians and pharmacies in the fall 

of2012 to support Part D sponsors' strengthened efforts to address this issue in the 

Part D program. In November 2012, as part of the armual Medicare "Dear Doctor" letter, 

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CMS encouraged prescribers to work with Part D sponsors on overutilization case 

management. 

In addition to these efforts, by leveraging our access to Part D claims data across all 

Part D sponsors, CMS is also conducting proactive data analysis to identify for Part D 

sponsors high-risk pharmacies and prescribers, allowing sponsors to better focus their 

anti-fraud efforts. An initial list of high-risk pharmacies was sent to plan sponsors in 

June 2013 and additional data-sharing is planned. These actions represent initial steps in 

what I anticipate will be a stronger partnership between CMS and Part D sponsors in 

combating Part D fraud and abuse. 

4. In your testimony, you said CMS is considering implementing strategies similar 

to the Fraud Prevention System and administrative actions into its management 

of the Part D program and its sponsors. However, the Inspector General's office 

has said most of the claimed "savings" from the system cannot be verified. 

a. Why is CMS considering this new direction, when the agency cannot 

successfully prevent egregious examples of fraud and waste at the 

moment? 

Answer: Based on CMS' analysis and the OIG's support, the Fraud Prevention 

System (FPS) shows significant promise and CMS expects results to improve as the 

system matures over time. CMS is committed to enhancing our ability to estimate savings 

with respect to both improper payments recovered and improper payments avoided for 

future reports, and we have been working very closely with the OIG to ensure they can 

verify the savings in future reports. We agree with the OIG, which acknowledged that 

reporting such amounts in accordance with requirements was inherently challenging 

because, primarily, it was a new venture and because of the decentralized nature of the 

Fraud Prevention System business practices. 

In addition, CMS is broadening its strategy to stop Part D fraud and abuse, and is using 

all the tools we have at our disposal to address these serious concerns, including, but not 

limited to, the lessons learned from the implementation of the Fraud Prevention System. 

We continue to consider strategies similar to the FPS to address fraud in Part D because 

CMS anticipates being able to identify patterns and practices potentially indicative of 

fraud or abuse that would not be apparent using only Part D or only Part A and B data. 

Data analysis is only the first step, however; after identifying questionable prescribing, 

dispensing or beneficiary utilization, CMS, along with the MEDIC or ZPIC must work 

with Part D plan sponsors to confirm if there may be a legitimate reason for such outliers 

and then, when appropriate, take administrative actions to prevent further payments 

resulting from abusive prescribing. While data sharing with Part D sponsors will enable 

them to impose controls to prevent payments where there are indications of fraud or 

abuse, CMS is exploring its regulatory options to respond to such indications, providing a 

more comprehensive safeguard for the program. 

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5. In your testimony, you said CMS recognizes that Part D plan sponsors face 

unique challenges in administering the drug benefit because they can manage 

the benefit only at the beneficiary level. They do not have access to Part D 

prescriber and pharmacy data beyond the transactions they manage for their 

own enrollees. 

a. What steps is CMS taking to share more complete, timely, and accurate 

data? 

Answer: eMS has access to all Part D data while plan sponsors only have access to their 

own Part D data. In order to provide more useful and timely data, eMS has begun 

sharing the results of its data analysis across the program with Part D plan 

sponsors. Specifically, we provided a list of pharmacies with a high risk assessment to 

plan sponsors to assist them in their fraud, waste and abuse detection efforts. eMS will 

provide this report to plan sponsors regularly and is also planning to release a prescriber 

risk assessment to plan sponsors. eMS will continue to explore ways to share additional 

data with plan sponsors to help them with their fraud, waste, and abuse efforts. 

6. The Inspector General's office found that imprOVements are needed to ensure 

the provider enumeration and Medicare enrollment data are accurate, complete, 

and consistent. In both data bases, roughly half of the information on providers 

was inaccurate and CMS did not verify most provider information in either 

database. eMS cannot keep fraud out the Medicare program if they cannot 

even ensure that the providers enrolled in the program have basic information 

that is complete, accurate, and verified. CMS concurred with the OIG's 

recommendations. 

a. What specific steps has CMS taken to resolve the issues in OIG's report? 

Answer: eMS agrees with the OIG and strongly believes that one of our most important 

roles in preventing and detecting Part D fraud, waste, and abuse is to responsibly manage 

and leverage our provider enrollment data. Over the past few years, eMS has made some 

important changes to our policies and operations. Specifically, eMS has changed our 

rules so that beginning in 2013 all prescribers' Part D drug claims are required to have a 

valid national provider number. Already, in the first quarter of 2013, 99.6 percent of all 

Part D claims were compliant with this requirement. eMS has begun working on 

developing mechanisms to further verify provider enumerator data and implement 

processes to deactivate NPIs when appropriate for potentially fraudulent providers. eMS 

is also proposing regulatory changes that would require all Part D prescribers to be 

validated as Medicare providers. 

b. Can you give the committee a timeframe or work plan for when the 

vulnerabilities will be finally addressed in total? 

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Answer: CMS continues to work on developing mechanisms to further verify NPPES 

and PECOS data. CMS is taking several actions to resolve this issue, including working 

on a process to rapidly deactivate NPls for practice locations that are determined to be 

invalid. In conjunction with other data obtained, CMS will take action to deactivate NPI 

records with invalid practice locations or other circumstances justifying deactivation. 

CMS has already implemented a method to immediately identify providers and suppliers 

who are deceased by obtaining the deceased provider data on a more frequent basis. 

In addition, CMS plans to use the Automated Provider Screening (APS) system to screen 

and validate provider and supplier information such as licensure and exclusion data in an 

effort to improve and standardize the enrollment data verification by the MACs. CMS 

plans to screen all initial enrollments, changes, and revalidation through APS for 

providers and suppliers of all risk levels. CMS also plans to analyze information from 

APS and other investigative methods to conduct ad hoc site visits using the National Site 

Visit Contractor to further validate information provided during the enrollment process. 

Because of the evolving nature of vulnerabilities, CMS is unable to identify a timeframe 

in which our oversight of provider enumerator data will be complete, but would be happy 

to provide the Committee with updates on our progress. 

7. eMS does not currently share information on providers who have had their 

billing privileges suspended as an "early alert" warning on potentially 

problematic prescribers with plans or state medical boards which license and 

discipline doctors. 

a. Are there good reasons why this does not occur? 

Answer: CMS agrees we need to share information regarding high risk prescribers with 

plan sponsors and states; we have recently begun work to help address this need. CMS is 

planning to release a prescriber risk assessment to plan sponsors, helping to identify for 

plans which providers may be prescribing inappropriately. CMS is also developing a 

process in which the MEDIC will share prescriber information with the Federation of 

State Medical Boards (FSMB). The information shared with the FSMB would be a 

compilation of the results of an investigation, proactive data analysis and lor complaints. 

b. When will eMS do that? 

Answer: CMS anticipates having the process in place by early 2014. 

8. The IG's office said they appreciate eMS's agreement to implement certain 

recommendations, but "many of the vulnerabilities that OIG has identified stem 

from a lack of basic checks that should be occurring." 

a. Will you give us a complete workplan and timeframe for when eMS will 

implement all of the recommendations? 

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Answer: Yes, per the request of the Committee, CMS plans to report on a periodic basis 

regarding our ongoing efforts to combat prescription drug abuse in the Part D program. 

9. Who checks to be sure a provider has a VALID DEA number before a claim is 

paid-a sponsor? Who checks to be sure a provider has a VALID DEA number 

after a claim is paid-a sponsor, the MEDIC? 

Answer: Under the Controlled Substances Act and regulations, it is the responsibility of 

the dispensing pharmacy to ensure the legitimacy of the prescription for a federally 

controlled substance that may only be prescribed by providers with valid DEA numbers. 

To assist pharmacies with this responsibility, a "public" version of the database of 

individual DEA numbers is commercially available for purchase through the U.S. 

Department of Commerce National Technical Information Service (NTIS). However, 

with respect to institutional DEA number (e.g., a hospital's number), the institution is 

required to keep a list of internal codes and the corresponding individual practitioners and 

to make the list available at all times to other DEA registrants and law-enforcement 

agencies upon request for the purpose of verifying the prescribing practitioner's 

authority. The DEA does not maintain a list of internal codes for each institution's DEA 

number. Thus, the internal codes cannot be verified electronically by a pharmacy, and 

there is no requirement for a publicly-available database that can be used to verify that a 

particular prescriber is authorized under an institutional DEA number. Under DEA 

guidance, pharmacists should contact the hospital or other institution for verification if 

they have any doubts in filling such a prescription. 

CMS' policy with respect to DEA numbers does not supersede or alter pharmacy 

obligations relative to the Controlled Substances Act and regulations. However, under 

Part D program law and regulations, in order to be a valid prescription all Part D drugs 

must be dispensed pursuant to all applicable state and federal laws, and invalid 

prescriptions may affect Part D sponsors' payments from CMS. Thus, sponsors do 

conduct certain, targeted point-of-sale (POS) checks before issuing payment for a 

prescription. Since sponsors are expected to take reasonable steps to ensure their network 

pharmacies are complying with all applicable laws without unreasonably delaying a 

beneficiary's access to medications, we have clarified this guidance to state that when a 

prescriber has an individual DEA number that can be cross referenced to the NPI, we expect 

Part D sponsors to confirm that the controlled substance prescribed is consistent with that 

prescriber's DEA Schedule registration. Ifthe sponsor cannot match the NPI to an individual 

DEA number, we do not require the sponsor to validate the DEA number. Thus, our 

guidance to sponsors is consistent with what sponsors are able to do with the publicly 

available databases described above. 

10. The TULSA WORLD recently ran a story about a senior who tragically lost her 

life under apparent neglect or malpractice from a physician with multiple 

serious infractions with the State's medical board. 

http://www.tulsaworld.com/article.aspxlPlea for help/20130623 11 Al CUTLI 

N2I3814 

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In such a case, I think most would agree Medicare should know about 

these multiple serious infractions, especially when a patient might be harmed. 

a. Under Medicare Part D, are sponsors required to get enforcement or 

infraction information on individual providers from the state medical 

boards? If they do so, how timely is that information, and how frequently 

is it updated? Do sponsors receive information from the Federation of 

State Medical Boards? If they do so, how timely is that information, and 

how frequently is it updated? 

Answer: CMS is proposing regulatory changes under section 6405 of the Affordable 

Care Act to require the Medicare enrollment of the prescribing provider in order for the 

Part D program to cover prescription costs. 

Currently, medical licenses are typically granted to physicians and other medical 

practitioners by the board of medicine in each state. A physician or other medical 

practitioner who does not have an active medical license in a state is not permitted to 

practice medicine in that state. CMS does not require that Part D sponsors access 

enforcement or infraction information from state medical boards because it is not a final 

action resulting in termination or suspension of medical licenses. For the purposes of 

fee-for-service Medicare, CMS will revoke a provider's enrollment ifthe provider does 

not have an active medical license or if a state licensing board's enforcement or infraction 

action is based on a felony conviction or other law enforcement action. The regulatory 

change we are considering under section 6405 would also include a proposal to allow 

CMS to revoke prescribers for similar infractions when determined appropriate. 

Additionally, certain felony convictions will result in exclusion by the OIG from all 

Federal health care programs, and Part D sponsors are responsible for checking the OIG 

exclusion list every month for their contracted prescribers. Part D sponsors may purchase 

access to the Federation of State Medical Boards to determine if a prescriber has had 

hislher license suspended or revoked in their particular state. 

b. Under Medicare Part C, arc plans required to get enforcement or 

infraction information on individual providers from the state medical 

boards? If they do so, how timely is that information, and how frequently 

is it updated? Do plans receive information from the Federation of State 

Medical Boards? If they do so, how timely is that information, and how 

frequently is it updated? 

Answer: Medical licenses are typically granted to physicians and other medical 

practitioners by the board of medicine in each state. If a physician or other medical 

practitioner does not have an active medical license in the state, they are not permitted to 

practice medicine, including participating in the Medicare program. 

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Additionally, certain felony convictions will result in an exclusion by the OIG from all 

Federal health care programs, and Medicare Advantage Organizations (MAOs) are 

responsible for checking the OIG exclusion list every month for their contracted 

prescribers. Additionally, MAOs may purchase access to the Federation of State Medical 

Boards to determine if a prescriber has had his/her license suspended or revoked in their 

particular state. CMS does not require that MAOs access infraction information from 

state medical boards because an infraction is not a final action resulting in termination or 

suspension of a medical license. 

c. Under Medicare Parts A and B, does CMS or its contractors receive 

enforcement or infraction information on individual providers from the 

state medical boards? If they do so, how timely is that information, and 

how frequently is it updated? Does CMS or its contractors plans receive 

information from the Federation of State Medical Boards? If they do so, 

how timely is that information, and how frequently is it updated? 

Answer: Medical licenses are typically granted to physicians and other medical 

practitioners by the board of medicine in each state. If a physician or other medical 

practitioner does not have an active medical license in the state, they are not permitted to 

practice medicine. CMS checks physicians' licensure status during the enrollment and 

revalidation process. CMS will revoke a provider's enrollment in fee-for-service 

Medicare if the provider does not have an active medical license. If a state licensing 

board's enforcement or infraction action is based on a felony conviction or other law 

enforcement action, CMS may revoke the provider's Medicare FFS enrollment based on 

those grounds. 

11. Why has the Medicare Appeals Council upheld the ability of Medicare to pay for 

DNA testing in recent months when these tests are not clinically needed or 

determinative? 

Answer: CMS is only aware of one Medicare Appeals Council decision on DNA 

Specimen Provenance Assignment (DSPA) testing, in February 2013; and, in that 

decision, the Council found that the DSP A tests at issue were not covered by Medicare. 

In this case, the Administrative Law Judge had previously found that the DSP A testing fit 

the definition of diagnostic testing and was covered as medically necessary for each of 

the beneficiaries whose claim was at issue. However, the February 2013 Medicare 

Appeals Council decision reversed the Administrative Law Judge's decision and found 

that the DSP A tests at issue were not diagnostic laboratory tests, were not otherwise 

within a Medicare benefit category, and were not covered by Medicare. 

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Senator Jeff Chiesa 

1. One way for prescription drug abusers to obtain controlled substances is to 

"doctor shop" which allows them to get prescriptions from multiple physicians, 

filled in several different pharmacies to avoid detection. What number of 

Medicare enrollees participate in "doctor shopping"? Of that number, how 

many ofthose are dual eligibiles? 

Answer: While it is difficult to identify a number or percentage of the full Medicare 

population, based on an algorithm used to identity opioid overutilization, eMS identified 

22,222 beneficiaries in 2011 that met our targeting criteria for potential opioid 

overutilizers, which includes doctor shopping. Of those beneficiaries, approximately 

16,000 were dually-eligible. The methodology excludes those beneficiaries who have 

legitimate diagnoses that may warrant high opioid use (e.g., cancer patients or others who 

need palliative care), or who are borderline cases. 

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Post-Hearing Questions For the Record 

Submitted to Gary L. Cantrell and Stuart E. Wright 

From Senator Tom Coburn 

"Curbing Prescription Drug Abuse in Medicare" 

June 24, 2013 

Questions from Senator Coburn: 

1. Is it accurate that it currently takes up to 12 months to exclude a provider from 

Medicare? If so, shouldn't CMS alert Part D sponsors about questionable providers 

before that time? 

OIG processes exclusions within a range of time periods. The exclusion process begins when 

another entity outside of DIG finalizes certain actions, such as a conviction or State professional 

board licensing action. Such an action triggers a potential exclusion determination by DIG. The 

timeframe in which OIG receives referrals of potential exclusions varies - currently, OIG is 

receiving referrals 130 days, on average, from the triggering action. Once DIG has received all 

relevant information from a referring entity, it takes six months, on average, to complete the 

exclusion process. 

OIG has recommended that CMS alert sponsors routinely about questionable providers. 

Specifically, in our report titled Retail Pharmacies with Questionable Part D Billing (OEI-02-

09-00600), OIG recommended that CMS analyze billing data to detect pharmacies with 

characteristics that indicate a high risk for fraud and provide this information to sponsors 

routinely to assist them in targeting pharmacies for auditing and further review. 

2. OIG recommends ensuring that Part D does not pay for refills of Schedule II drugs, 

since such refills are prohibited by Federal law. Yet, OIG suggests this is happening. 

• Are you saying that CMS is not adequately enforCing current Federal law? 

Who at CMS is failing to do so? 

• How would CMS fix this? 

In 2009, Medicare Part D inappropriately paid $25 million for Schedule II drugs billed as refills. I 

Sponsors should not have paid for any of these claims because Federal law prohibits the refilling 

of Schedule II controlled substances. Paying for such drugs raises public health concerns and 

may contribute to the diverting of controlled substances. 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. 

Some of these drugs may have been inaccurately billed. It is possible that some long-term-care 

pharmacies incorrectly billed these drugs as refills when the drugs were dispensed as partial fills. 

Partial fills, which are allowable for Schedule II drugs under certain conditions, occur when a 

pharmacist does not dispense all doses of the prescribed medication at one time. Several 

concerns exist, however, if partial fills are inaccurately billed as refills. For example, if some of 

t OIG, Inappropriate Medicare Part D Payments/or Schedule II Drugs Billed as Refills, OEI-02-09·00605, 

September 2012, 

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these refills were actually partial fills and were not accurately billed as such, beneficiaries and 

the Government may have overpaid for copayments. Incorrect billing affects the accuracy of 

Prescription Drug Event (PDE) data, which can hinder efforts to ensure payment accuracy and to 

detect and prevent fraud, waste, and abuse. 

To address these findings, OIG recommends that CMS issue guidance to sponsors to prevent 

billing of Schedule II refills and to ensure accurate billing of partial fills. OIG also recommends 

that CMS exclude Schedule II refills when calculating payments to sponsors. 

3. OIG recommends strengthening the MEDIC's monitoring of prescribers and 

pharmacies on a more data-driven, proactive basis. 

• In your opinion, could CMS do this under its current contract with the 

MEDIC? Would it need a contract modification? 

According to the MEDIC's current statement of work, the MEDIC is required to detect and deter 

fraud, waste, and abuse in Parts C and D and to perform proactive data analysis. We believe that 

the MEDIC could improve its monitoring of prescribers and pharmacies by strengthening its 

proactive data analysis to identify those with questionable patterns. CMS concurred with the 

recommendations in our reports to strengthen the MEDIC's monitoring of pharmacies and to 

expand its analysis ofprescribers.2 Furthermore, CMS stated that it will continue to work with 

the MEDIC to accomplish this analysis. 

We believe the MEDIC could do this under its current contract without a contract modification. 

However, OIG defers to CMS to respond to questions about its contract details. 

• What rules currently hold the MEDIC back from sharing data with States or 

other entities? 

As described in an OIG report from January 2013,3 the MEDIC reported in June 2012 that it was 

prohibited by CMS from sharing specific information related to its investigations and cases, such 

as a beneficiary'S or provider'S billing history, with other program integrity contractors, such as 

Zone Program Integrity Contractors (ZPIC). The MEDIC explained that it can share general 

schemes and summary data but not specific information. 

In comments to our draft report, CMS explained that this was true early in the MEDIC program 

because ofa regulatory restriction (42 CFR 423.322). However, according to CMS, Section 

6402(b) of the Patient Protection and Affordable Care Act (ACA) authorized the MEDIC to 

share specific information related to its investigations and cases with other HHS contractors. 

However, CMS added that because of a conflict of interest with one ZPIC, the MEDIC had been 

instructed not to share specific claim information until the conflict of interest was mitigated. 

Because it was unclear with whom the MEDIC could share information, OIG recommended that 

CMS instruct the MEDIC when it can share specific information with other entities, including 

2 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, May 2012 and Prescribers With 

Questionable Patterns in Medicare Part D, OEI-02-09-00603, June 2013. 

3 MEDIC Benefit Integrity Activities in Medicare Parts C and D, OEI-03-1 1-00310, January 2013. 

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119 

ZPICs and State agencies. CMS concurred with this recommendation and provided guidance to 

the MEDIC in January 2013. This guidance stated that Section 6402 of ACA authorized the 

MEDIC to share Part C and Part D data with any Medicare contractor for the purpose of 

oversight, evaluation, and enforcement of the Medicare program. However, it is not clear to OIG 

whether this guidance permits the MEDIC to share Part C and Part D data with State agencies. 

• Why do CMS regulations prohibit the MEDIC from obtaining information 

directly from entities such as pharmacies, physicians, and pharmacy benefit 

managers? 

Current regulations at 42 CFR 423.505(i)(3)(iv) require sponsors' contracts to specify whether 

these entities should produce information either to the plan sponsor to provide to CMS, or 

directly to CMS or its designees (e.g., the MEDIC). Therefore, the choice of whether the 

information can be directly obtained by the MEDIC is determined by the sponsor. 

In comments to our draft report on November 5, 2012, CMS did not concur with our 

recommendation to amend regulations to authorize the MEDIC to directly obtain information 

from these entities. CMS stated that it chose not to be prescriptive with respect to the choice of 

method for providing the information. OIG will continue to monitor this issue. 

4. OIG recommends CMS recover payments from plan sponsors for inappropriate Part D 

claims. 

• Would this best be accomplished by the Part D RAC or the MEDIC? 

Unlike the Parts A and B fee-for-service program where CMS pays the providers directly and 

has the claims processors collect overpayments, the Part D program works under a capitated 

payment methodology where CMS pays plan sponsors advance monthly payments and the plan 

sponsors pay providers for prescription drugs and other services. Part D sponsors also receive 

low income subsidy, reinsurance, and, in some cases, risk corridor payments that are linked to 

claims data submitted to CMS and reconciled after the end of the plan year. Although the 

identification of the inappropriate payments could be accomplished by the MEDIC or the Part D 

RAC, the recovery of any payments from sponsors would likely take place during the 

reconciliation process by CMS. In other words, CMS would ultimately determine who would 

recover funds associated with inappropriate Part D claims. 

5. DIG had recommended that CMS require sponsors to verify that prescribers have the 

authority to prescribe drugs. 

• Is that something that you think CMS could do quickly? 

• Could you comment on the workability or degree of ease for plans in 

operationalizing that? 

OIG did not assess how quickly or easily CMS could implement this recommendation. That 

said, eMS did concur with OIG's recommendation and provided comments on the draft report. 

Specifically, CMS stated that it would "issue guidance requesting our sponsors to include a 

retrospective review in their required programs to combat fraud, waste, and abuse where data 

anomalies, such as those identified by OIG in this report, suggest possible inappropriate 

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120 

prescribing and to report any potential fraud to the MEDIC for further investigation." CMS also 

stated that current PDE guidance provides Part D sponsors with a process to delete PDEs that are 

fraudulent. PDEs from prescribers confirmed by the MEDIC as not having prescribing authority 

would be communicated back to sponsors, who would then delete the PDEs and implement 

point-of-sale edits to reject claims from these unauthorized prescribers in the future. CMS did 

not comment on when these changes would be implemented. 

6. OIG said "it is important that CMS effectively follow through and implement these 

basic checks." 

• Has CMS given you a timeframe or workplan for ANY of the 

recommendations you have made in either of your two recent reports? 

CMS has not given 010 a timeframe in which they would implement these 

recommendations. However, CMS is required to provide oro with a corrective action plan (i.e., 

final management decision) addressing recommendations made in each report within six months 

of issuing the final report. For OIO's recent reports discussed in the hearing, we anticipate 

receiving CMS's corrective action plans by December 21, 2013. In these documents, CMS 

should describe actions that it plans to take to address our recommendations as well as 

timeframes for completing such activities. 

• Once OIG makes a recommendation, how often does OIG follow-up with the 

agency to ensure progress has been made in accomplishing it? 

Within six months of issuing a final report, the agency provides 010 with a final management 

decision detailing its plan to address report recommendations. For those recommendations with 

which the agency concurs or plans to take action to address, 010 requests that the agency send a 

status update on its progress each year until the 010 considers the recommendation 

implemented. 

7. OIG suggested requiring diagnosis codes on Part D claims to help determine whether a 

drug is covered under Medicare. 

• Would this be costly to implement? 

Commercial plans merely look for drug utilization to inform certain 

diagnosis (like cancer) and then examine the outliers. Couldn't the MEDIC 

use that approach? 

In the report Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents 

(OEI-07-08-00150), 010 recommended that CMS "facilitate access to information necessary to 

ensure accurate coverage and reimbursement determinations." Specifically, 010 stated that 

diagnosis codes could help drug plan sponsors and CMS ensure that a drug meets the definition 

of a Part D-covered drug (i.e., is used for an indication approved by the Food and Drug 

Administration or a medically accepted indication supported by specified compendia). 

OIO made this recommendation to ensure that claims are paid only for drugs covered by Part 

D. OIO did not analyze the costs of requiring diagnosis codes on Part D claims. The MEDIC 

could look for outliers of utilization of certain drugs as one approach to look for questionable 

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121 

prescribers or beneficiaries. However, OIG remains concerned that CMS is paying for drugs that 

are not covered by Part D. We believe that it is important for sponsors and the MEDIC to have 

access to information, such as the diagnosis codes, to determine whether a drug is covered. 

8. Who checks to be sure a provider has a VALID DEA number before a claim is paid? 

What information do you currently receive from the DEA? Would more be helpful? 

After clarification from Josh Trent, staff for the Committee, OIG understands that the first part 

of this question was intended to address checks on providers with valid National Provider 

Identifier (NPI) numbers rather than DEA numbers (because CMS now requires only NPI 

numbers). Mr. Trent explained that the question was also intended to inquire whether the Fraud 

Prevention System (FPS) checks for valid NPI and DEA numbers. 

OIG defers to CMS on questions related to the FPS. We note that CMS issued a final rule with 

comment period that would effectively require plan sponsors to check a provider's NPI number. 

Currently, Part D plan sponsors submit PDE records to CMS after they reimburse pharmacies for 

Part D enrollees' prescription claims. On April 12,2012, CMS issued a final rule with comment 

period that requires plan sponsors to submit to CMS only PDE records that contain an active and 

valid individual prescriber NPI. The rule also requires sponsors to ensure that the lack of an 

active and valid individual prescriber NPI on a network pharmacy claim does not unreasonably 

delay a beneficiary's access to a covered Part D drug. The new rules are effective for PDEs 

submitted on or after January 1,2013. [77 Federal Register 22143-22148] 

As outlined in Chapter 5 of the Prescription Drug Benefit Manual, Part D sponsors are also 

required to confirm the validity of DE A numbers on claims for Schedule II-IV drugs (or map the 

prescriber NPI to a valid individual DEA number) and confirm that the controlled substance is 

consistent with the DEA Schedule registration.4 However, CMS clarified in a May 21, 2013 

memorandum to Part D sponsors that when a prescriber is prescribing under the DEA 

registration of a hospital or institution and does not have an individual DEA registration, CMS 

does not require plan sponsors to reject these claims for controlled substances. In the 

memorandum, CMS stated its belief that information is not available to sponsors to allow them 

to map an individual prescriber's NPI onto an institution's DEA registration; CMS also 

expressed concern that rejecting claims in these circumstances could impede beneficiary access 

to necessary medications.s 

Regarding DEA information, OIG receives active and retired registrant information. We also 

obtain other supporting information about Controlled Substance schedules from another source. 

OIG communicates openly with DEA and other partners on a number of activities, including 

enforcement and fraud detection efforts. OIG will continue to coordinate with DEA on specific 

data sets and information sharing in the future. 

4 CMS, Medicare Prescription Drug Benefit Manual- Chapter 5, Section 90.2.4, September 20, 2011. Available at: 

http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/MemoPDBManu"IChapterS 093011.pdf. 

5 CMS, Clarification of Chapter 5 of the Prescription Drug Manual, Sec. 90.2.4 - Controlled Substances, May 21, 

2013. Available at: http://www.ama-assn.org/resources/doc/washington/cms-controlled-substances-prescribingmemo-21may2013.pdf. 

5 
122 

Post-Hearing Question for the record 

Submitted to Gary L. Cantrell and Stuart E. Wright 

From Senator Jeff Chiesa 

"Curbing Prescription Drug Abuse in Medicare" 

June 24, 2013 

Question from Senator Chiesa: 

1. One way for prescription drug abuse to obtain controlled substances is to "doctor shop" 

which allows them to get prescriptions from multiple physicians, filled in several 

different pharmacies to avoid detection. What numbers of Medicare enrollees 

participate in "doctor shopping"? Ofthat number, how many ofthese are dual 

eligible? 

OIG has not conducted analysis on this topic. However, in 2011, the General Accountability 

Office (GAO) issued a report on this topic entitled, Instances o/Questionable Access to 

Prescription Drugs. According to this report, GAO found indications of doctor shopping in the 

Medicare Part D program. Specifically, about 170,000 beneficiaries received the same class of 

frequently abused drugs, such as hydrocodone and oxycodone, from five or more prescribers in 

2008.6 About 72 percent of these beneficiaries received the Medicare Low-Income Subsidy. 

OIG plans to conduct a future review to determine how selected Part D sponsors are detecting 

and deterring overutilization of Part D drugs by beneficiaries. 

6 GAO, Instances of Questionable Access to Prescription Drugs (GAO· 1 1·699). Available at: 

http://www.gao.gov/assets/590/585424.pdf. 

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123 

Post-Hearing Questions for the Record for the 

Senate Homeland Security and Governmental Affairs Committee Hearing: 

"Curbing Prescription Drug Abuse in Medicare" 

Submitted to Alanna Lavelle 

From Senator Tom Coburn 

1. You have experience in law enforcement and industry. WellPoint uses a controlled substance 

utilization monitoring program in their commercial and Medicaid business and has also 

implemented a restricted recipient program for Medicaid plans. WellPoint supports giving 

eMS the authority to establish a restricted recipient program in Medicare Part D for those 

beneficiaries displaying a pattern of misutilization. 

o What kinds of successes have you seen with this program? (Restricted Recipient 

Program) 

o How many beneficiaries on average may be affected? 

o Can you talk a little bit about misperceptions you have heard about the merits of 

this well-designed tool? (Restricted Recipient Program) 

Response: 

Attached is an exhibit outlining details of our experience with various state restricted recipient 

programs in the Medicaid arena. 

Some say that the Part D multi-payer design (where some plans are solely stand alone pharmacy) 

creates challenges for implementing a restricted recipient program. However, only when the 

problem is discussed in detail can any challenges be addressed and overcome. Some also 

contend that a restricted recipient program can create a barrier between beneficiaries and needed 

care. State Medicaid programs have not found this to be the case and in fact such programs have 

been found to often help beneficiaries get the appropriate care management necessary. In 

addition, any issues can be addressed through beneficiary appeals to more narrowly tailor the 

beneficiary restrictions. While eMS has been unsure that a restricted recipient program would be 

more effective in preventing prescription drug abuse than enhanced DUR procedures, I it should 

be noted that in its April 2012 call letter eMS now permits s¥onsors to implement beneficiaryspecific point-of-service restrictions under certain conditions. Thus, it appears that eMS may 

be open to the concept of a restricted recipient program, and it bears further discussion and 

exploration. 

I Testimony of Jonathan Blum, Director, Center for Medicare Management, October, 20 II, found at: 

http://www.hhs.gov/asl/testify/201Iil0/t20111004a.html 

2 CMS Memo, "Announcement of Calendar Year (CY) 2013 Medicare Advantage Capitation Rates and Medicare 

Advantage and Part D Payment Policies and Final Can Letter," April 2, 2012, found at: 

http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/downloadsl Announcement20 13.pdf 
124 

2. WellPoint's Special Investigation Unit refers every Part D case to the MEDIC, and WellPoint 

has the second highest number of referrals to the MEDIC nationwide. 

o Could you describe the kind of relationship you have with the MEDIC? Do you 

think the current contract is very effective? 

o How would you like to see the MEDIC contract modified? 

Response: 

We have, and continue to have, a good, working relationship with the MEDIC. However, we 

have some recommendations on how the MEDIC and Part D fraud investigations could be made 

much more effective than they are currently. These recommendations include: 

• Hire the MEDIC investigators as employees with fuJI investigatory powers. A 

central problem in the use of a contractor, the MEDIC, rather than federal govemment 

employees is that MEDIC investigators lack legal investigatory authority and as such are 

hampered in their investigations. We recommend that MEDIC investigators be hired as 

federal govemment employees in OIG, perhaps as GS-1810s, so that they have full 

investigatory powers. While we realize that the orG has been laying off employees due 

to budget cuts and sequestration cuts, hiring orG fraud investigators would result in 

significant savings to the Medicare trust fund. 

• End the subcontractor relationship with MEDIC. A second problem results from the 

retention of a subcontractor, Rainmaker Solutions, in January 2011. This subcontracting 

relationship interferes with communications between sponsors and the MEDIC and has 

consequently made sponsors' fraud investigations less effective. We recommend that the 

subcontractor relationship not be retained and that funds used to hire the subcontractor be 

used for better purposes to fight fraud and abuse. 

• Improved communication from DOJ and law enforcement to plan sponsors. A third 

problem is that sponsors experience lack of feedback from federal prosecutors and law 

enforcement on cases they have referred once a decision to prosecute a case has been 

made. Even public facts of record such as indictments, pleas, convictions, and sentencing 

are not communicated to sponsors. Sponsors are forced to query public databases to 

discover the statuses of cases they referred to the MEDIC, which adds inefficiency to the 

process. We recommend that once an indictment is filed, federal law enforcement or the 

Department of Justice communicates that fact to the sponsor that originally referred the 

case, and that the sponsor is also infonned of guilty pleas, convictions, sentencing and 

restitution. 

3. In your testimony, you said plan sponsors are rarely infonned of the ultimate result, and 

infonnation collected by the agency is rarely shared with the private payers and said CMS 

does not share infonnation on revoked Medicare providers with private payers. 

o Can you talk about the negative impact this has on the sponsors who are trying 

to fight waste and fraud in their plans? 

o What other information would you like to have from CMS? 

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125 

Response: 

At a minimum, we would like CMS to share with sponsors in a timely fashion the lists of 

excluded providers, as well as the lists of providers who have been disciplined. 

While CMS currently does share provider revocations with sponsors, it takes about a year before 

the exclusion lists are up to date on the CMS website. In order to be most fully effective in their 

anti-fraud programs, sponsors need to know within a short period of weeks whether a provider 

was revoked. Too great a period of time between revocation and communication to sponsors 

gives those providers carte blanche in the interim to defraud the Medicare Part D program. 

There is a list of disciplinary proceedings against providers available but only to law 

enforcement, not sponsors. This lack of communication also unnecessarily hamstrings sponsors' 

anti-fraud investigations. 

As an example of the lack of federal information sharing reSUlting in increased plan losses, in 

20 lOwe identified a Florida provider who was billing for infusion therapy of a drug that was not 

infused. By the time we identified this provider, we had paid out over $9.5 million in fraudulent 

claims in the past year. Once we put a stop pay on those claims, we were able to prevent $2.5 

million more fraudulent claims from this provider from being paid. When we referred this 

provider to the HHS OIG, we were informed that the provider had been a person of interest to 

OIG for several years. Two and one-half years after contacting the OIG, the federal investigation 

is ongoing due to switches in personnel, the provider is still in practice, and federal agencies are 

unable to identify where the fraudulently billed funds are. Presumably the fraud is ongoing. 

4. In your testimony, you said WellPoint recommends that dual eligible beneficiaries with 

evidence of drug-seeking behavior should be locked into one managed care plan, rather than 

continue to be allowed to switch plans on a monthly basis to evade detection. 

o Would you be willing to review draft legislation from my office on this topic? 

Response: Yes, we are willing to review draft legislation on this issue. 

5. In your testimony, you warned that the Medical Loss Ratio in the Affordable Care Act 

effectively "means that insurers will have to include as administrative expenses their largest 

portion of antifraud expenses -- those dedicated to fraud prevention." You said "It is truly 

puzzling that at a time when the federal govemment is accelerating its efforts to prevent 

fraud in Medicare and Medicaid it has simultaneously issued regulations that will serve to 

discourage health insurers' fraud prevention efforts in the private and public sectors." 

o How would you recommend Congress modify existing MLR regulations 

to address this problem? 

Response: Currently the Medicare Advantage MLR (which is also applicable to Part D) permits 

sponsors to include in their incurred claims fraud prevention expenses up to the amount of fraud 

recoveries (i.e., amounts collected from fraud perpetrators).3 The Medicare Advantage MLR 

regulation can be amended as follows to permit sponsors to include fraud prevention expenses as 

'42 C.F.R. § 422.2420(b)(2)(ix). 

3 
126 

related to "activities that improve health care quality.,,4 This recommendation recognizes the fact 

that Part D anti-fraud investigations lead to improved patient safety by avoidance of 

overprescription. 

We realize that concerns have been raised that if the MLR credit were expanded to include fraud 

prevention expenses greater than fraud recoveries, there might be no effective control on the 

anti-fraud program expense included in the MLR calculation. To address that concern, we 

suggest that a cap be placed on the anti-fraud program expenses similar to that imposed on 

expenses for ICD-IO compliance and implementation. 

Additionally, some have contended that the MLR formula should not be altered because the 

return on investment (ROI) for anti-fraud programs is very favorable. It's important to 

understand that the ROI for anti-fraud programs takes into account fraudulent claims prevented. 

However, in the Part D context, the savings (the returns) recognized by anti-fraud programs inure 

not to the benefit of the plan sponsor, but to CMS and ultimately beneficiaries in the form of 

lower Part D premiums. Thus, under the current MAIPart D MLR rules a Part D plan sponsor 

must fund its anti-fraud program out of its capital and surplus and is only given credit in the 

MLR for fraud recoveries, which are a very small part of total fraud savings. We believe that a 

portion of the savings should be returned to the plan sponsor to support effective anti-fraud 

programs in Part D. 

Sample regulatory language is as follows (changes appear in bold underline or strikeout): 

42 CF.R. § 422.2420 Calculation of the medical loss ratio. 

(2) The MLR for an MA contract-

(ii) That includes MA-PD plans (defined at § 422.2) must also reflect costs and 

revenues for benefits described at § 423.l04(d) through (f) of this chapter. 

(b) Determining the MLR numerator. 

(1) For a contract year, the numerator of the MLR for an MA contract (other than 

an MSA contract) must equal the sum of paragraphs (b)(l)(i) through (iii) of this 

section, and the numerator of the MLR for an MSA contract must equal the sum 

of paragraphs (b)(l)(i), (iii), and (iv) of this section. The numerator must be 

determined in accordance with paragraphs (b)(5) and (6) of this section. 

(2) Incurred claims for clinical services and prescription drug costs. 

(i*) Claims PlIYmeBts Fee9¥enes as a Fesult of Houd FeduetioB effoFts, Bot to 

eneed the amouBt of Hood FedoetioB e*peBses. 

4The regulation requiring Part D sponsors to implement measures addressing drug overutilization categorizes drug 

overuse as a "quality assurance" activity, and supports this recommendation. See 42 C.F.R. § 423.153 Drug 

utilization management, quality assurance, and medication therapy management programs (MTMPs). 

4 
127 

42 C.F.R. § 422.2430 Activities that improve health care quality. 

(a) Activity requirements. Activities conducted by an MA organization to 

improve quality must fall into one of the categories in paragraph (a)(J) of this 

section and meet all of the requirements in paragraph (a)(2) of this section. 

(l) Categories of quality improving activities. The activity must be designed to 

achieve one or more of the following: 

(i) To improve health outcomes through the implementation of activities such as 

quality reporting, effective case management, care coordination, chronic disease 

management, and medication and care compliance initiatives (including 

restricted recipient and lock-in programs), including through the use of the 

medical homes model as defined for purposes of section 3602 of the Patient 

Protection and Affordable Care Act, for treatment or services under the plan or 

coverage. 

(iii) To improve patient safety and reduce medical errors through the appropriate 

use of best clinical practices, evidence-based medicine, and health information 

technology under the plan or coverage. 

(b) Exclusions. Expenditures and activities that must not be included in quality 

improving activities include, but are not limited to, the following: 

(5) Establishing or maintaining a claims adjudication system, including costs 

directly related to upgrades in health information technology that are designed 

primarily or solely to improve claims payment capabilities or to meet regulatory 

requirements for processing claims, including ICD-IO implementation costs in 

excess of 0.3 percent of total revenue under this part, and maintenance ofICD-lO 

code sets adopted in accordance with to the Health Insurance Portability and 

Accountability Act (HIP AA), 42 U.S.c. 1320d-2, as amended. 

(8) Expenses attributable to fraud prevention activities in excess of 0.5 percent 

of total revenue under this part. 

6. In your testimony, you talked about the importance of risk scores for claims before they are 

paid. You said WellPoint's Special Investigations Unit has opened 200 investigations and has 

achieved $27 million in projected savings to date. 

o In your experience, is the MEDIC for Part D doing anything like this? 

o Do you have any experience with CMS's Fraud Prevention System? 

Response: 

• We are not aware of the MEDIC using risk scores for claims in Part D. 

5 
128 

• Any experience we have with CMS' Fraud Prevention System would be through our 

subsidiary, National Government Services (NGS). 

7. Who checks to be sure a provider has a VALID DEA number before a claim is paid? 

Response: 

Our phannacy benefit manager checks for valid DEA numbers of prescribers. However, the 

issue is not whether a provider has a valid DEA number. Rather, the problem is that entities are 

fraudulently obtaining NPIs (National Provider Identifiers), and if an entity has an NPI, it can 

then fraudulently get a DEA number. When checked, NPPES (National Plan and Provider 

Enumeration System), the subagency that administers the NPI system, will affirm that an NPI 

number fraudulently obtained is indeed valid. But the underlying data and assertions upon which 

an NPI was granted could be false, as they are never verified. For example, last week our SIU 

discovered a false NPI and called NPPES to check. The NPPES staff person affirmed that she 

simply assigns NPIs over the Internet with no verification. For example, the NPI application 

allows use of a P.O. Box as a mailing address, which makes it very easy for fraudsters to defraud 

the government - they don't even have to set up a false storefront. 

We understand that when CMS first issued the requirement for NPIs there was a need for 

providers to get NPIs in an administratively simple and easy manner so that providers could meet 

compliance deadlines. However, at this juncture there is a need to identify and prevent provider 

fraud by tightening the procedures and verification around entities applying for new NPIs. 

The items of information that a person or entity is required to input in applying for an NPI are as 

follows: 

Information Required for Individual Providers 

• Provider Name SSN (or ITIN if not eligible for SSN) 

• Provider Date of Birth 

• Country of Birth 

• State of Birth (if Country of Birth is U.S.) 

• Provider Gender 

• Mailing Address 

• Practice Location Address and Phone Number 

• Taxonomy (Provider Type) 

• State License Information 

• Contact Person Name 

• Contact Person Phone Number and E-mail 

Information Required for Organizations 

• Organization Name 

• Employer Identification Number (EIN) 

• Name of Authorized Official for the Organization 

6 
129 

• Phone Number of Authorized Official for the Organization 

• Organization Mailing Address 

• Practice Location Address and Phone Number 

• Taxonomy (Provider Type) 

• Contact Person Name 

• Contact Person Phone Number and E-mail 

We recommend that at a minimum, the NPPES should obtain the following information before 

issuing an NPI to verify that a person or entity is who he/she/they say they are. 

1. Copy of government issued document (passport, state driver's license, etc.) for the 

person or entity making the application. 

2. For corporations - a copy of the Secretary of State - Division of Corporations 

document showing they are a state licensed entity. 

3. Copy of state issued license (pharmacy, medical license, etc.). 

Additionally, the NPPES should require the individual or organization to supply a street address 

rather than a P.O. Box as a mailing address. 

7 
130 

~ 

WELLPOINT, 

State Medicaid Provider Assignment Or Lock-In 

Programs And Requirements 

State SmunuH') of State lock-in Program 

!n,.,~m"n"tes <:;Ip!tlit.ifl1ealthpfl\f1S rTl'W i,,,,,,,aJ,ljari!la'6;lock'lJ\ programt!;,j! conlbrms to Stite.ieqwieine\tts. 

l . Members .,e.locked-lttfura 12-"",i!lhp~riOd ~I)d <:anon!y <>blalpMedlC;\!1d ~nbed d~~ servkes(roma il~igtlated 

f p!)ar",~<:y ~""Vid~' an<l frolJl nMtlJe~ 1!~lder..'lb~.State<leslgnat!!$ the p~at"'""Y to )Vhlcrr jbereclpi<!ntl/lmb,,: '. 1o~1r\ .. Members releasedafter.thel~-month ~e~~1j.~re.oot!fled vI!' a.letter30 d.ys;p,lol-Il'Om d!s;j!~"""nt 

fN~wi¥. enrolle<!.melnbersilre p~tmltted t!l""'pqnd '24 d.y$·~ tII),-rete,pt oft!)" lock4ri lette'8Il4 req,",~ flj' a 1. different presCtlptjon .• nd!or"~e.lof tM.d"tislon; All newly enrolled members a", asslgl1l!d a case ",.nager and 

I' a:~ gl~~~n ini~al a~s~~t . • M.mi",rt{llJi<l!l "II~~":Cu't't\tlY;tII.State has481 meinbers In Its loCk-in program. To meet the requirements for 

I<?~ft..in.. ~Nl~~mbet'ii\ustharv~~oug~t three or mo~ opi~S from three or MQfe di~erent prescribers at more'than 

three ph.rmacles in" 90-daypetlod. 

Health plans participating in Georgia's Program Integrity Program, which locks-in members to pharmacies and a Primary 

Care Physician {pcPt must allow members to change pharmacies for good cause, such as recipient relocation or the 

pharmacy does not provide the prescribed drug; provide case management and education reinforcement of appropriate 

medication use; annually assess the need for lock-in for each member; and provide monthly reporting on the program 

to the Department of Community Health. Members enrolled in the program are locked-in for a 12-month period. Members 

have a 10-day window to fife a grievance to appeal the decision. 

1> Mem:ber lodNf! (,it1;r1-$: There are currently 2,324 members enrolled in the program. To meet the requirements 

for !ock~in, the member must have sought and/or used two or more prescribers and two or more pharmacies and 

five or more controls with three or more opioids in last 45 days . 

. • l~dia~.w6tks dlte!'tlyWithhea'ilh plans !olmp'emetlt the thr .. -tieredControiled StJi'stance Utilization MonJtorlng : (<;SUI,n;l1r;ocesi:, wIIleh lo~~.,ll1 m~mber t<> pharmacies an\! a PCP .. The CSUM process inc\udes:. (i) membe, 

at\1j. provide, aw"renl!SSof nee.dls.idi!11!\fied; (l! prior authorization fur an controlled substanceS; and, ~l.~mbers 

. Identifledto have ,~u~ilIe pa1'\"msarelbcklld:ln to • specifiC Pharmacy:fui. 2Ji..month petiod and.re given • .30,. 

(. daywlntiow to re'pond to the. lru;l<,ln reques). 

~ M~~Ht»r t@c;mJ~} tflte4~c; r~~~ '~~e ~t,lffe~1~ ~ tne~f'$ {oc~d~try.1o m?et the J~qui~e~nts ~ora tqck"!l1~ a Il1<!mber.",ust be !ei:.eIVih~.m!!dl~on from three or m"rePhy,tClans \'fifOm three or Il"'ta ph.imaol!!s ani! 

ten or more narcotm m.dill\>t1~n;\restllption,. The member'spmfllemust norm.et critena f<>r.mMIlcaln.~ity 

0' a phy$ICian h"s.not.su~pl!ed diagliQSi, .of need fot ",gl",e". A member also quallfies]f theyweterefe"ed to. 

l=SUMdll~ t<>,~~sp'<ll>d't;lUd;~\lt!t •• reportso! stolen prescriptions, re1>eated 10ss01 prescrlptions,.co!l$isteot, 

~ll~SCrt'Ptio~,~ftn,too 'sooo'3?d fr~,!ent emergency department viSi~s. 

Currently, the State mandates the pharmacy, PCP and hospitalslock~in requirements for health plan participation 

to include monitoring and educational tools for persistent member non~compliance with Managed Care Organization 

(MeO) requirements; engaging in abusive or threatening conduct; committing fraud or abuse of medical benefits; 

and, overutilization of Medicaid services. Members identified as potentia! enrollees receive a warning letter and 

if their behavior does not improve within 60 days of receipt, they are locked~in. Locked~in members are initially 

enrolled for a 24-month period; however, if enrollment continues beyond this timeframe, there is no definite 

date of termination. Members have 30 days from the date of the certified letter to respond with a grievance. 

} Me,nh1N' j,J)ttHIl Cdt>2'f\a; There are currently 163 members locked~in. Members qualify for lockwin for concurrently 

obtaining services from two or more providers of the same spedalty, not in the same group practice, with no referrals; 

using two or more emergency facilities for nonpemergent diagnoses; consistently seeking/obtaining medica! services 

which are not supported by diagnosis or medica! records/documentation; excessive inpatient hospital services; or, 

excessive and/or duplicative medications, supplies, appliances, durable medica! equipment or outpatient services. 

Members may also meet the requirements by visiting two or more pharmacies, two or more prescribers and five or 

more controlled substance claims, of which three must be opiolds in a 4S-day period. A member also qualifies if they 

are suspected of fraud, such as reports of stolen prescriptions, repeated loss of prescriptions, consistent prescription 

refill too soon and frequent emergency department visits. 

~~~;~;. ;Ian, partiCipa~~!~lO~I~:;;~p~~;";acy "nd p(1)Vidersl'lC~i~p,o~ram.must ailow members to ch~rige phatrriad~, fotgoedcause; sudfa."'<:i!>"nt rel",,"lip,; o,~'phi>rmlky<!o~ nptpmvide the prescribed druID jlmvide 

casemal1agement al1d i.du~tiO"~lnforte~nt ohp~ri~e me?icallonUS<l; and. blannuaily .asse". the need fer 

lock-in for .each membe1fIMl)<j.ltllpla!l m!lStalSOp«Wlde.thame~har acc<!sS. to., 72·hout emergency supply "f 

meditatiOn atphartnatles»th<lrtl\a!1 tfj.d"lghated~~~l1f>arrlja<:y.EliIlibl. ""'m~rs.are iocked-in for .l~month 

period. Members haVe ~ l<Blay wind<;w;o:(1!$wndal1dfll~. gljevancetegardlngthe lock-Itt. 

/< !>lem", 1J).~;ill ()'~~; There .rel!ll.ril<'mbe~ eu"~nt1y enrOlled in'tlie progiam: T"meetthe requirements fur a 

l¢ck4n, tile m~mb.r musthavesOugljt \)Veor mo", Ilrescrtbers and two or more pharmacies andfiveor mdre contrQls 

with three or more oplo1ds In the past 45 days. 

712GB 
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Currently, the State mandates health plan requirements for participation in the Corrective Managed Care {eMe} 

Program, The program monitors and promotes appropriate use of controlled substances. The program identifies 

members who appear to be receiving duplicate conttoned drug therapy, visiting multiple prescribers and/or 

patronizing multiple pharmacies to obtain controlled substances. Member information is shared with prescribers, 

pharmacy providers and PCPs in order to prevent any abuSive behavior, If/ despite the best efforts of the prescriber and 

pharmacist, there still conti nues to be overuti!iz3tion or perceived misuse of a controlled substance by a member, 

the member can be locked-in. Under a lock-in pharmacy agreement, the recipient wi!! be required to fill prescriptions 

for all medications paid fee-for-service at one predetermined pharmacy, Members found eligible are initially 

enrolled for six-, 12-, 18- or 24-month periods and the health plan is responsible for tracking this process. 

~ f'11€:mhcf lod!'011 Crlti2ri,[j: There are currently 121 members locked~in, Members qualify for lock-in for seeking 

six or more opiate prescriptions and three or more different providers in a one-month period, two or more 

opiate prescriptions each for at least 360 doses in a three-month period or discharged by a provider because of 

suspected opiate prescription fraud . 

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There are currently 659 members enrolled in the program. Note: Contract and member lock-in program criteria 

follow process Similar to Louisiana. See the State of Louisiana for more information. 

Currently, the State requires all members residing in Medicaid Managed Care mandatory counties and for Family 

Health Plus are subject to a 12-month pharmacy and provider lock-in period. Members have an initial90-day 

grace period during which they may disenroll without cause. The local district of sodal services is responsible 

for notifying members of their right to change health plans in their enrollment confirmation notice, The State 

Department of Health is responsible for providing notice of the end of the Jock-in and the right to change health 

plans at least 60 days prlor to the first enrollment anniversary date. 

¥ MJJim'b~v li:}(:k~~n ((l'tq;ri~; There are currently 432 members locked-in. To meet the requirements for a lock-in, the 

member must have sought two or more prescribers and two or more pharmacies and five or more controls with 

three or more opioids in the past 45 days. 

Currently, the State ofTennessee handles its own lock-in program. Participating health plans are required to provide 

the State with the necessary data to identify potential pharmacy lock-in candidates. 

There are currently 68 members locked-in. Note: Contract and member lock-in program criteria follow CSUM 

process, See program criteria for Indiana for more information. 

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