PBMs, Medicare Advantage, Fraud Just Three Topics to Keep Track Of

John Marcille

Turn around for just one second and health plans find all sorts of issues racing toward them. There is, of course, the ferment taking place in the pharmacy benefit management industry that Thomas Reinke ably examines in our cover story.

Developments on deadline include Karen Ignagni, president and CEO of America’s Health Insurance Plans, pointing out that the government is considering drastic cuts to Medicare Advantage that will put the entire program at risk. Ignagni objects to the Medicare Advantage payment rates for 2010 that are “based on the assumption that Medicare physician payments will be cut by 21 percent — a policy everybody agrees Congress will never let go into effect.”

Meanwhile, a new Government Accounting Office report, titled “Fraud and Abuse Related to Controlled Substances Identified in Selected States,” alleges that tens of thousands of Medicaid beneficiaries and providers were involved in fraudulent purchases of controlled substances through the Medicaid programs in California, Illinois, New York, North Carolina, and Texas.

About 65,000 Medicaid beneficiaries in the five selected states acquired the same type of controlled substances from six or more different medical practitioners during fiscal years 2006 and 2007, with the majority of beneficiaries visiting from 6 to 10 medical practitioners. Such activities, known as doctor shopping, resulted in about $63 million in Medicaid payments and do not include medical costs (e.g., office visits) related to getting the prescriptions. As plans beef up their information technology systems, will they do a better job of catching these things?

These are just three of the many issues that need to be tracked. We’ll do our best.

Career Opportunities

HAP, a subsidiary of Henry Ford Health System, is a nonprofit health plan providing coverage to individuals, companies and organizations. This executive develops strategies to meet membership and revenue targets through products, pricing, market segmentation and advertising.  Aligns business among Business Development, Commercial Sales, Medicare and Public Sector Programs and Product Development. Seeks to enhance and be responsible for business development and expansion through the development of an effective product portfolio, strong interpersonal relationships and service excellence.

Apply via email to jfedder1@hfhs.org or online at http://p.rfer.us/HENRYFORDlXqAJA

Subscribe to Our Newsletters

Monthly table of contents

Be notified as each issue of Managed Care is available online.

Biweekly newsletter

Recent topics have included:

PTCommunity news

New drug approvals, clinical trials, drug management. Three times per week.


Managed Care
By Peter Wehrwein
Managed Care
By Howard Wolinsky