Industry News

OIG Reports on Part D Sponsors Voluntary Reporting of Fraud and Abuse Data.

Lisa Shuman | March 2014

The Department of Health and Human Services Office of Inspector General (OIG) recently reported on a study related to Medicare Part D sponsors voluntarily reporting of fraud and abuse data to the Centers for Medicare & Medicaid Services (CMS).  The report also addresses whether CMS used the reported data to monitor the Part D program.  The OIG conducted the study by examining fraud and abuse data reported by Part D plan sponsors from 2010 through 2012 and by surveying CMS about its review and use of the reported data. 

The OIG found that more than half of Part D plan sponsors did not report data on potential fraud and abuse between 2010 and 2012.  Sponsors reported identifying a total of 64,135 incidents of potential fraud and abuse between 2010 and 2012.  Notably, sponsors identification of incidents widely varied from 0 to almost 14,000 incidents a year.  The OIG noted that 28 percent of Part D plan sponsors reported that they did not conduct inquiries and implement corrective actions in response to incidents of potential fraud and abuse for the 2010 through 2012 time period.  CMS performed summary analyses of the data on potential fraud and abuse; however, the agency did not perform quality assurance checks on the data or use them to monitor the Part D program. 

The OIG recommended that CMS: (1) modify regulations to require sponsors to report to CMS their identification of and response to potential fraud and abuse; (2) issue guidelines to sponsors describing how to define and count incidents, related inquiries, and corrective actions; and (3) use data to determine the reasons for sponsors reporting particularly high or low numbers of incidents, related inquiries, and corrective actions; and (4) share sponsors’ data on potential fraud and abuse with all sponsors and law enforcement.  CMS concurred with the third recommendation, partially concurred with the second and fourth recommendations, and did not concur with the first recommendation. 

The OIG report is available at:

https://oig.hhs.gov/oei/reports/oei-03-13-00030.pdf.

Department of Health and Human Services Office of Inspector General.  “Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse.”  OEI-03-13-00030.  04 Mar. 2014. 

About the Author

Ms. Shuman assists health care organizations to develop, implement and evaluate their compliance programs and HIPAA privacy programs. Ms. Shuman specializes in our firm’s HIPAA Privacy services, including leading privacy investigations, breach risk assessments, breach notification letters, breach reporting to the Office for Civil Rights and corrective actions plans. She specializes in serving as Interim Privacy Officer for large health care systems, managed care organizations, comprehensive cancer center and health care business associate.

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