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

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.

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