Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

PRESCRIBERS WITH 

QUESTIONABLE PATTERNS

IN MEDICARE PART D

Daniel R. Levinson 

Inspector General

June 2013

OEI-02-09-00603
PRESCRIBERS WITH QUESTIONABLE PATTERNS IN MEDICARE PART D 

OEI-02-09-00603

WHY WE DID THIS STUDY

Under the Medicare Part D program, the Centers for Medicare & Medicaid Services 

(CMS) contracts with private insurance companies, known as sponsors, to provide 

prescription drug coverage to beneficiaries who choose to enroll. In recent years, 

prescription drug abuse has emerged as a serious and growing problem. The Centers for 

Disease Control and Prevention has characterized prescription drug abuse as an epidemic. 

With the rise in prescription drug abuse, concerns about Medicare fraud, particularly 

prescriber fraud, have increased. 

HOW WE DID THIS STUDY

We based this study on an analysis of Prescription Drug Event records. Sponsors submit 

these records to CMS for each drug dispensed to beneficiaries enrolled in their plans. 

Each record contains information about the pharmacy, prescriber, beneficiary, and drug. 

We analyzed all of the records for drugs billed in 2009. We developed five measures to 

describe Part D prescribing patterns and to identify general-care physicians with 

questionable patterns. 

WHAT WE FOUND

Over 1 million individual prescribers ordered drugs paid by Part D in 2009. Prescribing 

patterns varied widely by specialty. Over 700 general-care physicians had questionable 

prescribing patterns. Each of these physicians prescribed extremely high amounts for at 

least one of the five measures we developed. For example, many of these physicians 

prescribed extremely high numbers of prescriptions per beneficiary, which may indicate 

that these prescriptions are medically unnecessary. Moreover, more than half of the 

736 general-care physicians with questionable prescribing patterns ordered extremely 

high percentages of Schedule II or III drugs, which have potential for addiction and 

abuse. Although some of this prescribing may be appropriate, such questionable patterns 

warrant further scrutiny. 

WHAT WE RECOMMEND

These findings show the need for increased oversight of Part D. We recommend that 

CMS: (1) instruct the Medicare Drug Integrity Contractor to expand its analysis of 

prescribers, (2) provide sponsors with additional guidance on monitoring prescribing 

patterns, (3) provide education and training for prescribers, and (4) follow up on 

prescribers with questionable prescribing patterns. CMS concurred with all four 

recommendations. 
TABLE OF CONTENTS

Objectives ....................................................................................................1 

Background ..................................................................................................1 

Methodology ................................................................................................5 

Findings...................................................................................................... 11

Over 1 million prescribers ordered drugs paid for by Part D 

in 2009 ........................................................................................... 11

Prescribing patterns varied widely by specialty.............................12 

Over 700 general-care physicians had questionable prescribing 

patterns ...........................................................................................15 

Conclusion and Recommendations ............................................................19 

Agency Comments and Office of Inspector General Response... ..21 

Appendixes ................................................................................................22 

A: Specialties of Part D Prescribers ..............................................22 

B: Part D Prescribing Patterns by Specialty .................................23 

C: Agency Comments ...................................................................24 

Acknowledgments......................................................................................28 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 1

OBJECTIVES

1. To describe Medicare Part D prescribing patterns. 

2. To determine how Part D prescribing patterns differ by prescribers’ 

specialties. 

3. To determine the extent to which general-care physicians had

questionable Part D prescribing patterns in 2009. 

BACKGROUND

The Medicare Part D program provides an optional prescription drug benefit 

to Medicare beneficiaries.1 The Centers for Medicare & Medicaid Services 

(CMS) contracts with private insurance companies, known as sponsors, to 

provide drug coverage to beneficiaries who choose to enroll. In 2011, 

approximately 36 million beneficiaries were enrolled.2

Prescription drug abuse is a serious and growing problem. The Centers 

for Disease Control and Prevention (CDC) has characterized prescription 

drug abuse as an epidemic. In 2010, approximately 7 million people in the 

United States were misusing prescription drugs.3 Moreover, overdoses of 

prescription painkillers—called opioids—are among the leading causes of 

accidental death in the United States.4

With the rise in prescription drug abuse, concerns about Medicare fraud, 

particularly prescriber fraud, have increased. A number of recent 

convictions have involved prescriber fraud. In one case, the owner of a 

pain clinic and a nurse practitioner prescribed large quantities of the 

painkiller oxycodone to patients without medical need, four of whom 

died.5 In a similar case, a physician knowingly allowed nonmedical 

personnel to prescribe commonly abused painkillers, such as oxycodone, 

1 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, 

P.L. 108-173. 2 The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary 

Medical Insurance Trust Funds, 2012 Annual Report of the Boards of Trustees of the 

Federal Hospital Insurance and Federal Supplementary Medicare Insurance Trust 

Funds, p. 10. Accessed at http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2012.pdf on 

July 6, 2012. 

3 National Institute on Drug Abuse, Topics in Brief: Prescription Drug Abuse, 

December 2011. Accessed at http://www.drugabuse.gov/publications/topics-inbrief/prescription-drug-abuse on September 18, 2012. 4 CDC, Unintentional Drug Poisonings in the United States, July 2010. 5 Federal Bureau of Investigation (FBI), Owner of Chantilly Pain Clinic Convicted of

Drug Trafficking, Fraud Charges, August 3, 2012. Accessed at 

http://www.fbi.gov/washingtondc/press-releases/2012/owner-of-chantilly-pain-clinicconvicted-of-drug-trafficking-fraud-charges on September 11, 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 2

morphine, and hydrocodone, to Medicare beneficiaries by using blank, 

presigned prescription forms.6 In a third case, a physician wrote medically 

unnecessary pain prescriptions for individuals who illegally distributed 

them.7

Despite these concerns, little information has been available about Part D 

prescribing patterns. Data about typical prescribing patterns and

prescribers with questionable patterns are important first steps in detecting 

fraud, waste, and abuse. 

This report is part of a larger body of work examining Part D billing.8

Another report identified pharmacies with questionable billing in 2009.9

A third report identified inappropriate Part D payments for Schedule II 

drugs billed as refills.10 A fourth report determines whether Medicare 

Part D paid for drugs ordered by individuals who do not have the authority 

to prescribe.11 In addition, a recent analysis of Part D claims by 

ProPublica found that some prescribers ordered large quantities of drugs 

that are potentially harmful, disorienting, or addictive.12

Prescription Drugs

Medicare Part D covers prescription drugs that meet certain requirements 

and are used for medically accepted indications.13 CMS considers a drug 

to be “prescription” if the Food and Drug Administration has determined it 

must be labeled “Rx only,” which means it cannot be dispensed without a 

prescription from a practitioner who is licensed to prescribe such drugs.14

6 FBI, Palmetto Physician Pleads Guilty To Illegal Prescription Drug and Medicare 

Fraud Conspiracies, March 18, 2010. Accessed at http://www.fbi.gov/tampa/pressreleases/2010/ta031810.htm on July 2, 2012. 7 U.S. Department of Justice, Operation Oxyclean: Independence Physician Pleads 

Guilty To $1 Million Drug-Trafficking Conspiracy. Accessed at 

http://www.justice.gov/usao/mow/news2011/baker.ple.html on July 6, 2011. 8

 All four reports are part of the Health Care Fraud Prevention and Enforcement Action Team 

Initiative (HEAT), which focuses on detecting health care fraud through innovative data 

analysis and enhanced cooperation among the Department of Justice, Office of Inspector 

General (OIG), and CMS. 9 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, May 

2012.

10 OIG, Inappropriate Medicare Part D Payments for Schedule II Drugs Billed As Refills, 

OEI-02-09-00605, September 2012. 11 OIG, Medicare Part: Drugs Ordered by Individuals Without Prescribing Authority,

OEI-02-09-00608, June 2013. 12 Tracy Weber, Charles Ornstein, and Jennifer LaFleur, Medicare Drug Program Fails to 

Monitor Prescribers, Putting Seniors and Disabled at Risk, ProPublica, May 11, 2013. 

Accessed at http://www.propublica.org/article/part-d-prescriber-checkup-mainbar on 

May 15, 2013.

13 42 U.S.C. § 1860D-2(e)(1). 14 CMS, Medicare Prescription Drug Benefit Manual, Chapter 6, Part D Drugs and 

Drug Formulary Requirements, § 10, February 2010. Also see 21 U.S.C. § 353(b)(1).
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 3

The types of practitioners that are licensed to prescribe drugs are 

determined by State law. 

The Drug Enforcement Administration (DEA) regulates certain drugs that 

have potential for abuse and dependence, called controlled substances. 

These drugs are divided into five schedules. Schedule II drugs have the 

highest potential for abuse of any prescription drugs legally available in 

the United States.15 They include stimulants and narcotics commonly used 

to relieve pain, such as oxycodone and morphine. Schedule III drugs, 

such as hydrocodone with acetaminophen, also have potential for abuse. 

DEA requires all practitioners who handle controlled substances to register 

with the agency.16

Prescriber Fraud and Abuse

A number of fraud schemes in Part D involve prescribers.17 Notably, 

prescribers sometimes operate “pill mills” or accept kickbacks. To operate 

a pill mill, a prescriber writes large quantities of prescriptions, usually for 

controlled substances that are not medically necessary and are often for 

people who are not their patients. A kickback is paid to a prescriber to 

write an unnecessary prescription that is then billed to Medicare. In other 

schemes, prescribers’ prescription pads or provider identification numbers 

are stolen or sold by prescribers; these items then are used to write illegal 

prescriptions or to submit claims to Medicare.

Detecting and Deterring Part D Fraud and Abuse

CMS relies on sponsors to help safeguard Part D from fraud and abuse. 

CMS requires sponsors to have compliance plans that contain measures to 

detect, prevent, and correct fraud, waste, and abuse.18 CMS recommends 

that sponsors use data analysis as a part of these plans.

19 Specifically, it

recommends that sponsors develop indicators and establish baseline data 

so that they can recognize abnormalities and changes in prescribing 

patterns.

15 Schedule I drugs currently have no accepted medical use in the United States. They

include drugs such as heroin. 

16 DEA registration grants prescribers Federal authority to handle certain schedules of 

controlled substances. See 21 CFR § 1301.11.

17 CMS, Prescription Drug Benefit Manual, Chapter 9, Part D Program to Control 

Fraud, Waste and Abuse: Use of Data Analysis for Fraud, Waste and Abuse Prevention 

and Detection, § 70.1.4, April 2006. Accessed at 

http://www.cms.gov/PrescriptionDrugCovContra/Downloads/PDBManual_Chapter9_FW

A.pdf on September 12, 2012. 18 42 CFR § 423.504(b)(4)(vi).

19 CMS, Prescription Drug Benefit Manual, Chapter 9, Compliance Program Guidelines, 

§ 50.6.9, July 2012. Accessed at http://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovContra/Downloads/Chapter9.pdf on September 12, 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 4

Sponsors are also required to have a Drug Utilization Review program to 

assist in preventing overutilization of prescribed medications.20 CMS 

recently issued guidance recommending that sponsors use data analysis as 

part of their Drug Utilization Review programs to identify beneficiaries 

who may be overutilizing opioids. Opioids include Schedule II controlled 

substances, such as oxycodone, morphine, and fentanyl. CMS also 

recommended that sponsors communicate with prescribers to ascertain the 

medical necessity of these drugs. 

Additionally, CMS contracts with a Medicare Drug Integrity Contractor 

(MEDIC) to detect and prevent fraud, waste, and abuse. Its 

responsibilities include identifying and investigating potential Parts C 

and D fraud and abuse, referring cases to OIG, and fulfilling requests for 

information from law enforcement.21 The MEDIC is required to identify 

potential fraud and abuse through external sources, such as tips, as well as 

proactive methods, such as data analysis.22 

CMS is responsible for the oversight of sponsors and the MEDIC. CMS 

conducts a number of different audits for sponsors, including onsite audits 

of their compliance plans.23 During these audits, CMS assesses the 

effectiveness of sponsors’ fraud and abuse programs. CMS evaluates the 

MEDIC’s performance annually.

Related Work

A recent OIG report found that 2,637 retail pharmacies had questionable 

billing in 2009.24 These pharmacies had extremely high billing for at least 

one of the eight measures we developed. For example, many pharmacies 

billed extremely high dollar amounts or numbers of prescriptions per 

beneficiary or per prescriber, which could mean that a pharmacy is billing 

for drugs that are not medically necessary or were never provided to the 

beneficiary. Among other things, the report recommended that CMS 

strengthen its monitoring of pharmacies, provide additional guidance to 

20 CMS, Announcement of Calendar Year (CY) 2013 Medicare Advantage Capitation 

Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, 

April 2, 2012. Accessed at http://www.cms.gov/Medicare/HealthPlans/HealthPlansGenInfo/Downloads/2013-Call-Letter.pdf on October 4, 2012. Also 

see CMS, Supplemental Guidance Related to Improving Drug Utilization Review 

Controls in Part D, August 31, 2012.

21 CMS, MEDIC Statement of Work, July 2009. 22 For more information on the responsibilities of the National Benefit Integrity MEDIC, 

see OIG, MEDIC Benefit Integrity Activities in Medicare Parts C and D, OEI-03-11-

00310, January 2013. 

23 For more information on CMS audits, see OIG, Audits of Medicare Prescription Drug 

Plan Sponsors, OEI-03-09-00330, December 2011. 24 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, 

May 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 5

sponsors on monitoring pharmacy billing, and further strengthen its 

compliance plan audits. CMS concurred with these recommendations.

Another recent OIG report found that Medicare Part D inappropriately 

paid $25 million for Schedule II drugs billed as refills in 2009.25 Sponsors 

should not have paid for any of these drugs because Federal law prohibits 

the refilling of Schedule II controlled substances without a new

prescription.26 Also, three-quarters of Part D sponsors paid for Schedule II 

drugs billed as refills, indicating that many sponsors do not have adequate 

controls to prevent these refills. Among other things, the report 

recommended that CMS issue guidance to sponsors to prevent billing of 

Schedule II refills and to exclude Schedule II refills when calculating 

payments to sponsors. 

Another OIG report found that Medicare Part D paid $1.2 billion in 2007 

for drugs with invalid prescriber identifiers (the identifiers had either 

never been assigned or had been retired).27 The report recommended that 

CMS conduct periodic reviews to ensure the validity of prescriber 

identifiers and require Part D plans to institute procedures to identify and 

review records containing invalid prescriber identifiers. 

An additional OIG report found barriers to the MEDIC’s benefit integrity 

efforts.28 These barriers included problems in the sharing of information 

and recovering inappropriate payments. The report also found that only a 

small percentage of the MEDIC’s investigations and case referrals resulted 

from proactive data analysis. In the 1-year study period, the MEDIC 

initiated just 209 Part D investigations from proactive methods, such as 

data analysis. 

METHODOLOGY

We based this study on an analysis of Prescription Drug Event (PDE) 

records from 2009, which we collected to undertake this body of work. 

Sponsors submit these records to CMS for each drug dispensed to 

beneficiaries enrolled in their plans. Each record contains information 

about the beneficiary, pharmacy, prescriber, and drug. We matched these 

25 OIG, Inappropriate Part D Payments for Schedule II Drugs Billed as Refills, 

OEI-02-09-00605, September 2012. 26 Federal law permits partial refills under certain circumstances. It is possible some of 

these drugs may have been inaccurately billed as refills when they were partial fills. 27 OIG, Invalid Prescriber Identifiers on Medicare Part D Claims, OEI-03-09-00140, 

June 2010.

28 OIG, MEDIC Benefit Integrity Activities in Medicare Parts C and D, 

OEI-03-11-00310, January 2013. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 6

records to data from the National Plan and Provider Enumeration System 

(NPPES) to obtain descriptive information about the prescribers. 

Sponsors are required to certify the accuracy, completeness, and 

truthfulness of their PDE data.29 Beginning in January 2012, they are also 

required to ensure that the prescriber identifiers on the PDE records are 

active and valid, meaning that they are currently assigned to a health care 

provider. 30 

PDE Data

We obtained all PDE records for covered Part D drugs with dates of 

service from January 1 to December 31, 2009. This amounted to 

1,070,149,994 PDE records. 

For each PDE record, we identified the identification number of the 

prescriber, which was generally a National Provider Identifier (NPI).

31

NPIs are assigned to many different types of health care providers. 

Having an NPI does not mean that an individual has the authority to 

prescribe drugs. For records that used other types of prescriber 

identification numbers, we used a crosswalk developed by OIG analysts to 

identify the prescriber’s NPI.32 

We matched each NPI to the NPPES to determine which PDE records 

were prescribed by individuals, as opposed to organizations (e.g., hospitals 

or group practices). We focused our review on individual prescribers 

because organizations may be associated with multiple prescribers. We 

identified 1,102,275 individual prescribers who were associated with 

1,026,983,870 PDE records. These records represent 96 percent of all 

PDE records in 2009. 

Using the National Drug Code (NDC) on the PDE record, we matched the 

PDE records to data from First DataBank. First DataBank contains 

information about each drug, such as the drug name and whether the drug 

29 42 CFR § 423.505(k).

30 Sponsors must also confirm that any controlled substances are consistent with the 

schedule of drugs that the provider is allowed to handle. CMS, Announcement of 

Calendar Year (CY) 2012 Medicare Advantage Capitation Rates and Medicare 

Advantage and Part D Payment Policies and Final Call Letter, April 4, 2011. 31 PDE records allow four types of prescriber identification numbers: NPIs, DEA 

numbers, State license numbers, and Unique [Physician] Identification Numbers (UPIN). 

32 To develop this crosswalk, we used information from the Services Tracking, Analysis, 

and Reporting System (known as STARS), the DEA database, and the NPPES. We were able 

to identify valid NPIs for 97 percent of the PDE records. The remaining 3 percent had 

missing identifiers or were billed with identifiers that we could not link to a valid NPI.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 7

is brand-name or generic.33 It also indicates whether a drug is a controlled 

substance and, if so, which schedule the drug is on (Schedule II or III).34 

Prescribing Measures 

We used five measures to describe Part D prescribing patterns. We 

developed these measures on the basis of the results of past OIG analyses 

and fraud investigations of Part D billing, as well as input from CMS staff. 

We calculated the five measures for each individual prescriber, then 

calculated the national average for each measure.

The five measures are: 

(1) average number of prescriptions per beneficiary,35

(2) total number of pharmacies associated with each prescriber, 

(3) percentage of prescriptions that were for Schedule II drugs, 

(4) percentage of prescriptions that were for Schedule III drugs, and 

(5) percentage of prescriptions that were for brand-name drugs. 

We calculated the total number of beneficiaries that each prescriber 

ordered drugs for by using the Health Insurance Claim Number (HICN) on 

the PDE record. We calculated the total number of pharmacies by using 

the NPI for each pharmacy or, if it was unavailable, the identification 

number for the pharmacy on the PDE record.36 For the purposes of this 

report, we use the term “prescription” to mean one PDE record.

Analysis by Prescriber Specialty

To identify the specialty for each prescriber, we matched the NPIs to the 

NPPES. The NPPES contains information reported by each prescriber, 

such as his or her specialty, address, and professional credentials, such as

33 First DataBank determines whether a drug is brand-name or generic based on the 

drug’s name.

34 A total of 0.002 percent of the PDE records had an NDC that did not match to First 

DataBank. We did not include these records in the analysis on Schedule II, Schedule III, 

or brand-name drugs. 35 This measure represents the average number of prescriptions one prescriber ordered per 

beneficiary. It does not represent the average number of prescriptions that each 

beneficiary received because a beneficiary can receive prescriptions from multiple 

prescribers. 36 To identify the number of pharmacies, we used the same method as in an earlier report. 

See OIG, Retail Pharmacies With Questionable Part D Billing (OEI-02-09-00600), 

May 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 8

M.D. or R.N. Providers report this information to CMS and must ensure 

that it is updated and accurate.37 

We identified each prescriber’s specialty based on the primary taxonomy 

code that he or she reported in the NPPES. The taxonomy code indicates 

a provider’s specialty and subspecialty, if any. For example, it may 

indicate that a prescriber is a family-medicine physician specializing in 

geriatric medicine. 

We then grouped the taxonomy codes for similar specialties. For 

example, we grouped all of the nurse practitioners together and all of the 

dentists together. We considered general-care physicians to be general 

practitioners, family practitioners, and internal medicine practitioners with 

no specialization or a specialization in adults or geriatrics.38 We 

calculated each group’s average for the five measures listed above.39 

Identification of General-Care Physicians With Questionable 

Prescribing Patterns

To identify prescribers with questionable patterns, we focused our analysis 

on general-care physicians in nonrural areas. We focused on general-care 

physicians because they are the most common type of Part D prescriber 

and they prescribed more than half of all Part D prescriptions in 2009. We 

focused on physicians who were located in nonrural areas because those in 

very rural areas may have different prescribing patterns due to their 

location. For example, these physicians may order unusually high 

numbers of drugs per beneficiary because there are fewer physicians or 

specialists in their areas. We considered physicians who were not located 

in a Core Base Statistical Area (CBSA)—a region around an urban center 

that has at least 10,000 people—to be in very rural areas.40 In total, we 

based this analysis on 86,818 general-care physicians and 

540,581,871 PDE records.41

37 When applying for an NPI, the provider signs a certification that the information is 

correct and that he or she agrees to provide notification of any changes within 30 days. 

CMS, National Provider Identifier (NPI) Application/Update Form, November 2008. 

Accessed at https://www.cms.gov/Medicare/CMS-Forms/CMSForms/Downloads/CMS10114.pdf on June 5, 2012. 38 We reviewed each specialty’s prescribing patterns to ensure that they were similar to 

the other specialties and that we could group them together. 

39 For this analysis, we included the 22 specialty groups that each had more than 

3 million PDE records. 

40 U.S. Census Bureau, Metropolitan and Micropolitan Statistical Areas. Accessed at 

http://www.census.gov/population/www/metroareas/aboutmetro.html on March 3, 2011. 41 For this analysis, we included general-care physicians who were associated with 100 or 

more PDE records that amounted to $100,000 or more. For the analysis of Schedule II 

and III drugs, we included prescribers associated with 100 or more PDE records for those 

drugs. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 9

To identify the general-care physicians who were very extreme outliers

compared to their peers, we took several steps. We first used a standard 

technique for identifying outliers, known as the Tukey method.42 Using 

this method, we identified 2,248 general-care physicians who were 

outliers (i.e., above the 75th percentile plus 3 times the interquartile range) 

on one or more of the five measures we reviewed. In analyzing these 

physicians’ prescribing patterns further, we identified the prescribers who 

were even more extreme outliers. These outliers corresponded to a 

threshold of at least the 75th percentile plus 4.5 times the interquartile 

range for each measure. 

We considered general-care physicians who exceeded one or more of 

these thresholds to have questionable prescribing patterns. Some of their

prescribing may have been appropriate. However, prescribing high 

amounts on any of these measures may indicate that a physician is 

prescribing drugs which are not medically necessary or that he or she has 

an inappropriate incentive, such as a kickback, to order certain drugs. It 

may also indicate that the prescriber’s identification number or 

prescription pad has been sold or stolen. We calculated the total amount 

Medicare paid for drugs prescribed by these general-care physicians.43

We then determined the extent to which prescribers with questionable 

prescribing patterns had certain characteristics in common. We identified 

each prescriber’s CBSA to determine whether they were concentrated in 

certain areas. We also determined which drugs were most commonly 

ordered by prescribers with questionable patterns. 

Lastly, we determined whether the general-care physicians with 

questionable patterns were associated with any of the 2,637 retail 

pharmacies with questionable billing that we identified in an earlier 

report.44 We considered a physician to be associated with a pharmacy if 

the pharmacy billed at least 25 percent of the cost of all the drugs that the 

physician prescribed in 2009. 

42 See J.W. Tukey, Exploratory Data Analysis. Addison-Wesley, 1977. The Tukey 

method traditionally sets the threshold at the 75th percentile plus 1.5 or 3 times the 

interquartile range. The interquartile range is calculated by subtracting the value at the 

25th percentile from the value at the 75th percentile. 43 We used three fields on the PDE records to calculate Part D payments: the ingredient 

cost, dispensing fee, and sales tax. This includes the amount paid by sponsors, the 

Government, and by, or on behalf of, beneficiaries.

44 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, 

May 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 10

Limitations

We designed this study to identify prescribers who warrant further 

scrutiny. None of the measures we analyzed independently confirm that a 

particular prescriber is engaging in fraudulent or abusive practices. 

We did not independently verify the accuracy of the PDE records or the 

data from the NPPES. In particular, we did not verify the information 

about prescribers’ specialties that they reported in the NPPES. 

Standards

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 11

FINDINGS

Over 1 million prescribers ordered drugs paid for by 

Part D in 2009

A total of 1.1 million prescribers ordered Part D drugs for Medicare 

beneficiaries in 2009. These prescribers included many specialties, such 

as general-care physicians, dentists, and nurse practitioners. 45 These 

individuals ordered over 1 billion prescriptions during the year. In total, 

Medicare paid $70.7 billion for these prescriptions.46 On average, these 

1.1 million prescribers each ordered Part D prescriptions costing $64,102. 

Prescribers typically did not order drugs for a very large number of 

beneficiaries, nor did they order many drugs per beneficiary during the 

year. On average, each prescriber ordered prescriptions for 

80 beneficiaries and averaged 6 prescriptions per beneficiary. 

Interestingly, more than half of the prescribers ordered fewer than 100 Part 

D prescriptions each during the year. Further, on average, prescribers 

ordered drugs that were dispensed at 32 pharmacies. Half the prescribers 

ordered drugs that were dispensed at 17 or fewer pharmacies. 

Two-thirds of prescribers ordered Schedule II or III drugs. Schedule II

drugs are controlled substances that have potential for abuse and may lead 

to severe psychological or physical addiction. They include drugs such as 

oxycodone and morphine. On average, 4 percent of the prescriptions from 

each prescriber were for Schedule II drugs. Schedule III drugs also have 

potential for abuse and include anabolic steroids, hydrocodone with 

codeine, and barbiturates. On average, 7 percent of the prescriptions from 

each prescriber were for Schedule III drugs. 

On average, about a quarter of the prescriptions ordered by each prescriber

were for brand-name drugs. Interestingly, 16 percent of prescribers did 

not order any brand-name drugs, while 10 percent of prescribers ordered

60 percent or more of their prescriptions as brand-name. Brand-name 

drugs tend to be more expensive than generic drugs. See Table 1 for more 

information on prescribing patterns. 

45 For the purposes of this report, general-care physicians include general practitioners, 

family practitioners, and internal medicine practitioners with no specialization or a 

specialization in adults or geriatrics. 46 This includes the amount paid by sponsors, the Government, and by, or on behalf of, 

beneficiaries.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 12

Table 1: Part D Prescribing Patterns for All Prescribers, 2009 

National Average 10th

Percentile

50th

Percentile

90th

Percentile

Average Number of Prescriptions per 

Beneficiary 6 1 3 16

Number of Pharmacies Associated 

With Each Prescriber 32 1 17 85

Percentage of Schedule II Drugs 4% 0% 0% 10%

Percentage of Schedule III Drugs 7% 0% 1% 23% 

Percentage of Brand-Name Drugs 27% 0% 25% 60%

Note: For the purposes of this report, we considered a prescription to be one PDE record. 

Source: OIG analysis of Part D data, 2012. 

Prescribing patterns varied widely by specialty

General-care physicians were the most common type of prescriber and 

ordered the majority of Part D prescriptions. General-care physicians 

accounted for 20 percent of all prescribers in 2009 and ordered two-thirds 

of all of Part D prescriptions in 2009. Dentists were the second most 

common type of prescriber, but were responsible for just 1 percent of 

Part D prescriptions overall. Nurse practitioners and physicians’ assistants 

were also common prescribers; together they represented 11 percent of 

prescribers and were responsible for a little less than 6 percent of the 

Part D prescriptions. See Table 2 for the most common specialties. See 

Appendix A for a more complete list. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 13

Table 2: Most Common Specialties of Part D Prescribers

Specialty Percentage of All 

Prescribers

Percentage of All 

Prescriptions

General Care 20% 65% 

Dentistry 14% 1% 

Nurse Practitioners 7%* 3% 

Physician Assistants 5% 2% 

Emergency Medicine 4% 1% 

Psychiatry 4% 3% 

Obstetrics and Gynecology 3% 1% 

Surgery 3% <1% 

Cardiology 2% 5% 

*The percentages of prescribers and prescriptions for nurse practitioners and physician assistants do not sum 

to 11 percent and 6 percent, respectively, because of rounding. 

Note: For the purposes of this report, we considered a prescription to be one PDE record. 

Source: OIG analysis of Part D data, 2012. 

General-care physicians ordered more prescriptions per beneficiary than 

other specialties. Overall, general-care physicians ordered an average of 

13 Part D prescriptions per beneficiary, which is more than double the 

national average of 6. Other specialties averaged fewer. For example, 

infectious disease specialists ordered 

an average of 11 prescriptions per 

beneficiary and nephrologists ordered 

an average of 10. (See Table 3.) In 

contrast, emergency medicine 

specialists ordered an average of two

prescriptions per beneficiary. See 

Appendix B for more information on 

prescribing patterns by specialty.

Specialties also differed in the 

number of pharmacies that filled each 

prescriber’s orders. Cardiologists, endocrinologists, and rheumatologists 

had the highest number of pharmacies that filled the drugs they ordered; 

each had an average of more than 80 pharmacies per prescriber. An 

average of 52 pharmacies filled the drugs ordered by each general-care 

physician. In contrast, dentists and nurse practitioners had fewer 

pharmacies that filled their prescriptions, averaging 12 and 23, 

respectively. 

Table 3: Specialties With the 

Highest Average Number of

Prescriptions per Beneficiary

Specialty Average 

General Care 13

Infectious Disease 11

Nephrology 10

Note: For the purposes of this report, we 

considered a prescription to be one PDE record.

Source: OIG analysis of Part D data, 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 14

Furthermore, specialties varied in their prescribing of controlled 

substances. A few specialties were more likely than others to order higher 

percentages of Schedule II or Schedule III drugs. On average, 14 percent 

of the prescriptions ordered by physical medicine and rehabilitation 

specialists were for Schedule II drugs. Surgeons and anesthesiologists 

were next, with 11 percent of their prescriptions being for Schedule II 

drugs. (See Table 4.) General-care 

physicians were less likely to order 

Schedule II drugs. On average, 2 

percent of the prescriptions ordered by 

general-care physicians were for 

Schedule II drugs. Some specialties 

rarely prescribed Schedule II drugs; 

cardiologists and endocrinologists 

averaged a little more than 0.3 percent 

each for their prescriptions. 

The specialties most likely to prescribe 

Schedule III drugs were surgeons, 

emergency medicine specialists, and 

dentists. On average, more than 14 percent of the prescriptions ordered by 

prescribers in each of these specialties were for Schedule III drugs. In 

contrast, 3 percent of the prescriptions ordered by general-care physicians 

were for Schedule III drugs. A few specialties, including cardiologists and 

gastroenterologists, rarely prescribed Schedule III drugs.

Lastly, some specialties were much more likely than others to order 

brand-name drugs. Ophthalmologists, pulmonologists, and 

endocrinologists commonly ordered brand-name drugs. More than half 

the prescriptions ordered by prescribers in these specialties were for 

brand-name drugs, on average. In contrast, 28 percent of the prescriptions 

ordered by general-care physicians were for brand-name drugs. Dentists 

prescribed only an average of 9 percent brand-name drugs. These 

differences may be due to the availability of generic equivalents for the 

drugs commonly used by these specialties. 

Table 4: Specialties With the 

Highest Average Percentage of 

Schedule II Drugs

Specialty Average

Physical Medicine and 

Rehabilitation

14%

Surgery 11%

Anesthesiology 11%

Note: For the purposes of this report, we 

considered a prescription to be one PDE record. 

Source: OIG analysis of Part D data, 2012. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 15

Over 700 general-care physicians had questionable 

prescribing patterns

In total, 2,248 general-care physicians were outliers on one or more of the 

five measures we reviewed.47 In analyzing these physicians’ prescribing 

patterns further, we identified 736 who were very extreme outliers; we 

considered these physicians to have questionable prescribing patterns. Each 

of these physicians prescribed extremely high amounts for at least one of 

the five measures we developed. (See Table 5.) Medicare paid 

$352 million for the Part D drugs that these physicians ordered. While 

some of this prescribing may be appropriate, physicians with such 

questionable prescribing patterns warrant further scrutiny. 

These 736 physicians were located throughout the nation. Los Angeles and 

New York had the greatest numbers, with 34 and 32 physicians, 

respectively. Philadelphia (22), Tampa (19), and Detroit (15) had the nextlargest numbers.

Table 5: General-Care Physicians Who Prescribed Extremely High Amounts by 

Measure, 2009

National 

Average for 

GeneralCare 

Physicians

Threshold for 

Extremely 

High Amounts 

for GeneralCare 

Physicians

Number of 

General-Care 

Physicians 

That 

Prescribed 

Extremely 

High Amounts

Average Number of Prescriptions per Beneficiary 13 71 108

Number of Pharmacies Associated With Each Prescriber 52 342 35

Percentage of Schedule II Drugs 2% 14% 343

Percentage of Schedule III Drugs 3% 14% 174

Percentage of Brand-Name Drugs 28% 68% 116

 Total Number of General-Care Physicians 736*

*

A number of prescribers exceeded multiple thresholds. As a result, the sum of prescribers exceeding the thresholds does not equal 

736.

Note: For the purposes of this report, we considered a prescription to be one PDE record.

Source: OIG analysis of Part D data, 2012.

47 Our review included 86,818 general-care physicians. To identify general-care 

physicians who were outliers, we first used the Tukey method, described in footnote 42.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 16

Examples of Questionable Prescribing Patterns

• Medicare paid a total of $9.7 million—151 times more than the average— 

for one California physician’s prescriptions. Most of this physician’s 

prescriptions were filled by just two independent pharmacies, both of which 

OIG identified as having questionable billing. 

• Seventy-eight percent of the prescriptions ordered by one Florida physician 

were for Schedule II drugs. For one beneficiary, this physician prescribed 

large quantities of four Schedule II drugs— a 605-day supply of morphine 

sulfate, a 524-day supply of oxycodone HCl, a 460-day supply of fentanyl, 

and a 347-day supply of hydromophone HCl. 

• Fifty-seven percent of one Tennessee physician’s prescriptions were for 

Schedule II or III drugs. This physician prescribed an average of 8 

Schedule II prescriptions for each of his 427 beneficiaries, who filled their 

prescriptions at 368 different pharmacies.

One hundred eight general-care physicians prescribed an 

extremely high number of prescriptions per beneficiary

Although some of this prescribing may be legitimate, ordering a high 

average number of prescriptions per beneficiary could mean that a 

physician is prescribing drugs that are not medically necessary. 

As shown in Table 5, 108 general-care physicians prescribed an extremely 

high number of prescriptions per beneficiary. These physicians each 

ordered an average of 71 or more prescriptions per beneficiary, which was

more than 5 times general-care physicians’ national average of 13. 

Further, 24 of these physicians ordered more than 400 prescriptions for 1 

or more beneficiaries. In one extreme case, an Ohio physician ordered 

more than 400 drugs each for 13 of his 665 beneficiaries. In total, this 

physician ordered 50,430 drugs that were dispensed by 100 pharmacies in 

18 States. This raises questions about whether these prescriptions were 

legitimate. In another example, a Texas physician ordered more than 

400 prescriptions each for 16 beneficiaries. He prescribed 700 or more 

drugs for 3 of these beneficiaries in 2009. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 17

Thirty-five general-care physicians had prescriptions filled by 

an extremely high number of pharmacies

This measure raises questions about whether these prescriptions were 

legitimate or necessary. For example, it may indicate that the physician’s 

identification number or prescription pad was stolen or sold and then used 

to write illegal prescriptions and submit false Medicare claims. 

Thirty-five general-care physicians each had prescriptions filled by at least 

342 pharmacies. This was over six times the national average of 52 per

general-care physician. In one case, prescriptions from one general-care 

physician in Illinois were filled by 872 pharmacies located in 47 States 

and Guam. Medicare paid $783,686 for these drugs. 

In another case, prescriptions from a general-care physician in New Jersey 

were filled by 608 pharmacies located in 41 States and Puerto Rico. 

Medicare paid $380,847 for these drugs. 

Overall, 483 general-care physicians ordered an extremely 

high percentage of Schedule II or Schedule III drugs, which 

have potential for addiction and abuse

Schedule II and III drugs have a high risk for abuse. Although some of 

this prescribing may be appropriate, prescribing a high percentage of these 

drugs may indicate that a physician is ordering medically unnecessary 

drugs, which may be used inappropriately or diverted and resold. Misuse 

of these drugs has serious human and financial costs. 

A total of 483 general-care physicians ordered an extremely high 

percentage of Schedule II or III drugs. Specifically, 343 general-care 

physicians ordered a high percentage of Schedule II drugs: at least 

14 percent of the prescriptions ordered by each of these physicians were 

for Schedule II drugs. This was seven times the national average for 

general-care physicians. The most common Schedule II drugs ordered by 

these physicians were oxycodone HCl, morphine sulfate, and methadone 

HCl. 

In one example, about 80 percent of the prescriptions ordered by one Ohio 

physician were for Schedule II drugs. Also troubling is that this physician 

had 106 Part D beneficiaries and 98 of them received oxycodone HCl. 

Another California physician ordered 115 Schedule II drugs for 

1 beneficiary in 2009. Medicare paid $425,711 for these drugs, which 

were dispensed by 11 pharmacies. In another case, 68 percent of a 

Wisconsin physician’s prescriptions were for Schedule II drugs. On 

average, he ordered about 14 Schedule II prescriptions for each of his 

300 beneficiaries. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 18

In addition, 174 general-care physicians ordered a high percentage of 

Schedule III drugs. Fourteen percent or more of the prescriptions ordered 

by each of these physicians were for Schedule III drugs. This is five times 

general-care physicians’ national average. The most common Schedule III 

drugs prescribed by these physicians were hydrocodone-acetaminophen, 

acetaminophen-codeine, and Suboxone. Interestingly, for five prescribers 

35 percent or more of the drugs each ordered were Schedule III. Four of 

these prescribers were located in Kentucky and the fifth was in Tennessee. 

One hundred sixteen general-care physicians prescribed an 

extremely high percentage of brand-name drugs

While some of this prescribing may have been appropriate, ordering a high 

percentage of brand-name drugs may indicate that a physician has

inappropriate incentives to order certain drugs because brand-name drugs 

are more expensive than generic.

A total of 116 general-care physicians prescribed an extremely high 

percentage of brand-name drugs. At least 68 percent of the prescriptions 

ordered by each of these physicians were for brand-name drugs, compared 

to general-care physicians’ national average of 28 percent. In one case, a 

California physician ordered 82 percent of his prescriptions for 

brand-name drugs. Medicare paid a total of $9.7 million for his 

prescriptions in 2009—151 times more than the average amount. He also 

ordered an unusually large number of prescriptions for Lovaza, which is a 

prescription Omega-3-acid. 

Further, 15 percent of these general-care physicians were 

associated with retail pharmacies with questionable billing

A total of 110 of the 736 general-care physicians were associated with one 

or more of the retail pharmacies we previously identified as having 

questionable billing. 48 In each case, the retail pharmacy billed for at least 

25 percent of the total cost of the Part D drugs that the physician 

prescribed in 2009. 

Most of the physicians were associated with one retail pharmacy with 

questionable billing; however, five physicians were associated with two

pharmacies each. In one case, 90 percent of one physician’s prescriptions 

were filled by two pharmacies with questionable billing. These 

prescriptions amounted to $3.1 million. 

48 OIG, Retail Pharmacies With Questionable Part D Billing, OEI-02-09-00600, 

May 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 19

CONCLUSION AND RECOMMENDATIONS

We found hundreds of general-care physicians nationwide with

questionable prescribing patterns. While there may be legitimate reasons 

for some of this prescribing, all of these physicians warrant further 

scrutiny. We found that many prescribed extremely high proportions of 

Schedule II or III drugs. These drugs have high risk for abuse and may be 

diverted and sold for profit. Many other physicians prescribed high 

numbers of drugs per beneficiary or high proportions of brand-name 

drugs, which may indicate that the prescriptions are medically 

unnecessary. Further still, some prescribers had their prescriptions filled 

at extremely high numbers of pharmacies, again raising concern about the 

legitimacy of the prescriptions.

These findings show the need for increased oversight of Part D. OIG is 

committed to continuing its investigations and audits of Part D and to 

following up on prescribers, as appropriate. CMS must take steps to 

effectively identify and prevent prescriber related fraud, waste, and abuse 

in Part D. 

We recommend that CMS:

Instruct the MEDIC to Expand Its Analysis of Prescribers

CMS should work with the MEDIC to ensure that it effectively and 

systematically monitors prescribers to identify those with questionable 

patterns. As this study shows, prescribing patterns vary significantly by 

specialty; therefore, taking specialty into account is an important step in 

identifying prescribers with questionable patterns. We recommend that 

the MEDIC expand the analysis in this report and review other specialties 

for questionable prescribing patterns. The MEDIC should use the 

measures in this report, as well as others it deems appropriate. 

Provide Sponsors With Additional Guidance on Monitoring 

Prescribing Patterns

CMS should provide additional guidance to sponsors on how to effectively

monitor prescribing patterns. CMS should emphasize the importance of 

using data analysis to identify prescribers with questionable patterns. 

Specifically, CMS should recommend that sponsors compare physicians 

with similar specialties when conducting such analysis. 

In addition, CMS recently issued guidance to sponsors on how to improve 

their Drug Utilization Reviews to prevent overutilization of certain Part D 

drugs. This guidance suggests that sponsors use PDE data to identify and 

follow up on beneficiaries who are receiving extremely high dosages of 

opioids. CMS should provide further guidance to sponsors suggesting that 

they identify prescribers who are associated with a high number of these 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 20

beneficiaries and refer these prescribers to the MEDIC or law enforcement if

fraud is suspected. 

Provide Education and Training for Prescribers

CMS should provide education and training to prescribers. Although 

CMS does not have a direct contractual relationship with prescribers under 

Part D, it is in the best position to assess and educate prescribers about 

prescribing patterns. CMS should provide prescribers with reports 

comparing their prescribing patterns to their peers’. Similar to the 

Comparable Billing Reports issued for other services, such as Part B, these 

reports would provide prescribers with important educational information 

and insight about their prescribing patterns. 

CMS should also conduct a communication and educational campaign for 

prescribers about the overutilization of prescription drugs. Specifically, 

the campaign should raise awareness about prescription drug abuse and to 

remind prescribers that Part D only covers drugs that are used for 

medically indicated purposes. It should also educate prescribers about 

what constitutes Medicare fraud and the potential consequences of 

committing it. These efforts will help to ensure that physicians prescribe 

drugs only for lawful purposes. 

Follow Up on Prescribers With Questionable Prescribing 

Patterns

In a separate memorandum, we will refer the general-care physicians with 

questionable prescribing patterns to CMS for appropriate action. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 21

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In its comments on the draft report, CMS concurred with all four of the 

recommendations. CMS concurred with our first recommendation and 

stated that it will continue to work with the MEDIC to expand its analysis 

of prescribers and build on the analysis of prescribing patterns provided by 

OIG in this report. Additionally, CMS has increased its monitoring of 

prescribers through the Part D Recovery Audit Contractor with which 

CMS has contracted to identify and recover improper payments in the Part 

D program. 

CMS concurred with our second recommendation and stated that it has a 

responsibility for monitoring prescribing patterns beyond the 

responsibility of sponsors, because it has all prescribing data for Part D 

and sponsors have prescribing data for only their enrollees. To help 

sponsors overcome limitations in the plan data, CMS will provide general 

guidance “red flags” to sponsors concerning aberrant and abusive 

prescribing patterns it detects that may not be apparent to individual 

sponsors. It also stated that, “as a part of its opioid overutilization policy, 

CMS has already provided the guidance to Part D sponsors that this 

recommendation suggests on the critical area of opioid prescription drug 

abuse.” In addition, the MEDIC will conduct a presentation on drug 

overutilization at the next quarterly fraud work group meeting. 

CMS concurred with our third recommendation and stated that it has 

already engaged in communication and education for prescribers about the 

overutilization of prescription drugs in the annual Medicare “Dear Doctor” 

letter (i.e., the Announcement About Medicare Participation for Calendar 

Year 2013). CMS also stated that it engaged in an additional initiative to 

provide training and education through the Medicare Learning Network. 

CMS concurred with our fourth recommendation and stated that it is 

committed to following up, as necessary, to determine whether the 

individual physician prescribing patterns are indications of likely fraud or 

abuse. 

We support CMS’s efforts to address these issues. For the full text of 

CMS’s comments, see Appendix C. 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 22

APPENDIX A

Specialties of Part D Prescribers

Specialty Percentage of All Part D Prescribers Percentage of All 

Part D Prescriptions

General Care 19.8% 65.5%

Dentistry 13.7% 0.6%

Nurse Practitioners 6.5% 3.4%

Physician Assistants 4.9% 2.1%

Emergency Medicine 3.7% 0.9%

Psychiatry 3.6% 3.0%

Obstetrics and Gynecology 3.4% 0.5%

Surgery 2.7% 0.4%

Cardiology 2.1% 5.2%

Anesthesiology 1.6% 0.3%

Ophthalmology 1.6% 1.3%

Neurology 1.2% 1.1%

Gastroenterology 1.1% 0.8%

Hematology and Oncology 1.0% 0.7%

Dermatology 1.0% 0.4%

Urology 0.9% 0.8%

Pulmonary 0.8% 1.0%

Nephrology 0.7% 1.3%

Physical Medicine and Rehabilitation 0.7% 0.4%

Endocrinology 0.5% 1.0%

Infectious Disease 0.5% 0.4%

Rheumatology 0.4% 0.8%

Other 27.8% 8.0%

Note: For the purposes of this report, we considered a prescription to be one Prescription Drug Event record. 

Source: Office of Inspector General analysis of Part D data, 2012.
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 23

APPENDIX B

Part D Prescribing Patterns by Specialty

Specialty 

Average Number 

of Prescriptions 

per Beneficiary

Average

Number of 

Pharmacies

Associated With 

Each Prescriber 

Average

Percentage of 

Schedule II 

Drugs

Average

Percentage of 

Schedule III 

Drugs

Average

Percentage of 

Brand-Name

Drugs

General Care 13 52 2.0% 2.7% 28.3%

Infectious Disease 11 34 1.6% 1.9% 42.5%

Cardiology 10 85 0.3% 0.5% 29.4%

Endocrinology 10 82 0.3% 1.4% 51.4%

Nephrology 10 69 0.9% 1.5% 29.4%

Psychiatry 10 30 2.5% 1.0% 34.6%

Rheumatology 9 96 2.3% 4.4% 20.5%

Pulmonary 8 61 0.9% 1.0% 56.7%

Neurology 7 56 2.3% 1.9% 36.7%

Hematology and 

Oncology 6 51 8.5% 4.0% 34.2%

Physical Medicine and 

Rehabilitation 6 41 14.2% 10.6% 23.8%

Nurse Practitioners 6 23 3.8% 3.5% 29.6%

Anesthesiology 5 15 10.7% 7.9% 26.4%

Gastroenterology 4 66 0.7% 0.9% 39.1%

Obstetrics and 

Gynecology 4 23 2.5% 3.2% 43.5%

Ophthalmology 4 72 0.5% 1.3% 59.4%

Urology 4 74 1.9% 4.3% 41.7%

Physician Assistants 4 24 5.6% 8.7% 23.5%

Dermatology 3 60 0.4% 1.4% 19.7%

Surgery 3 23 10.9% 18.8% 21.7%

Emergency Medicine 2 32 7.8% 14.8% 15.8%

Dentistry 2 12 1.4% 14.2% 8.7%

Note: For the purposes of this report, we considered a prescription to be one Prescription Drug Event record. 

Source: Office of Inspector General analysis of Part D data, 2012. 
APPENDIXC 

Agency Comments 

Centers for Medicare & Medicaid Services 

Administrator 

Washington, DC 2020 t 

MAY - 6 2013 

DATE : 

TO: Daniel R. Levinson 

Inspector General 

FROM: Matilyn enner 

Actirrg Administrator 

SUBJECT: Office oflnspector General (OIG) Draft Report: "Prescribers with Questionable 

Patterns in Medicare Part D" (OEI-02-09-00603) 

The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 

comment on the above-subject OIG draft report. The purpose ofthis report is to describe 

Medicare Part D prescribing patterns, to describe the extent to which Part D prescribing patterns 

differ by prescribers' specialties, and to identifY general-care physicians with questionable 

Part D prescribing patterns in 2009. 

Prescription drug abuse is a serious and growing problem. CMS is committed to preventing such 

abuse, particularly in the area of prescriber fraud. CMS relies on sponsors to help safeguard 

Part D from fraud and abuse. These sponsors are required to have compliance plans in place that 

enable them to detect, prevent, and correct fraud, waste, and abuse. Additionally, CMS 

recommends that the sponsors use data analysis as part oftheir compliance plans. CMS also 

contracts with a Medicare Drug Integrity Contractor (MEDIC) as part ofits continuing effort to 

detect and prevent fraud, waste, and abuse. This contractor's responsibilities include identifYing 

and investigating potential Part D fraud and abuse, referring such cases to OIG, and fulfilling 

requests for information from law enforcement. 

We appreciate OIG's efforts in working with CMS to increase oversight of the Medicare Part D 

program in an effort to safeguard against prescription drug abuse. CMS concurs with all of 

OIG's recommendations to improve oversight ofPart D and to expand the use ofdata analysis in 

these oversight efforts. Our response to each ofthe OIG recommendations follows. 

OIG Recommendation 

The OIG recommends that CMS should instruct the MEDIC to expand its analysis of prescribers. 

Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 24 
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 25
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 26
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 27
Prescribers With Questionable Patterns in Medicare Part D (OEI-02-09-00603) 28

ACKNOWLEDGMENTS

This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New York regional 

office, and Nancy Harrison and Meridith Seife, Deputy Regional 

Inspectors General. 

Miriam Anderson served as the team leader for this study. Other Office of 

Evaluation and Inspections staff from the New York regional office who 

conducted the study include Jenell Clarke and Jason Kwong. Central 

office staff who provided support include Eddie Baker, Jr., Kevin Farber, 

Meghan Kearns, Christine Moritz, and Debra Roush. 
Office of Inspector General

http://oig.hhs.gov

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components:

Office of Audit Services

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.