New Report Highlights Growing Trend of Medicare Part D Fraud & Opioid Abuse

Medicare Part D provides prescription drug coverage for enrollees. However, a recent report highlights possible abuse and fraud – particularly pertaining to addictive opioids.
Image source: Wikimedia Commons

Over the next two posts, we will examine a recent report published by the Office of Inspector General, along with the U.S. Department of Health and Human Services. In the report, which is entitled “Questionable Billing and Geographic Hotspots Point to Potential Fraud and Abuse in Medicare Part D,”[1. http://oig.hhs.gov/oei/reports/oei-02-15-00190.pdf] authorities review the alarming epidemic of drug diversion and prescription drug abuse, particularly among the elderly population eligible for Medicare benefits.


In today’s post, we will review the background of the issue, the spending statistics, and the incongruent growth of controlled substance spending versus overall prescription drug costs. In tomorrow’s post, we will examine evidence surrounding pharmacies with questionable prescription drug statistics, as well as certain highlighted geographic “hotspots” and the highest-prescribed prescriptions in those areas. We will also review the OIG’s summarization of the problem – and what to do to possibly curtail this costly, wasteful, and deadly trend.

Medicare Part D & prescription drug coverage

There are several components to Medicare coverage, including general doctor visits, hospitalization, and prescription drugs. Medicare Part D is the component which allows for coverage of prescription drug costs, and currently covers nearly 39 million Americans.[2. http://kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/] Part D, which is optional for Medicare enrollees, is administered with the help of individual private health insurers known as plan sponsors. These plan sponsors are considered the first line of defense against fraud and are responsible for monitoring retail pharmacies to ensure compliance.

Prescription drug abuse

According to the Centers for Disease Control, prescription drug abuse of medications containing opioids is a nationwide epidemic. In 2011, the CDC was made aware of nearly 1.4 million emergency room visits across the United States linked to prescription drug abuse. This practice, known as drug diversion, occurs when patients are able to access certain drugs – including Percocet, Vicoden, or Oxycodone – either in violation of the parameters of their prescription or through purchase from an unauthorized source.

Also within the OIG’s report is information regarding the confounding practice of non-opioid prescription drug abuse. According to reports, the most common non-opioid drugs abused by patients nationwide include respiratory and anti-psychotic medications.

Spending for Medicare Part D has doubled since its inception

Unlike Medicare itself, which has been around since the Johnson administration, Medicare Part D prescription drug coverage has been in place since just 2006.[3. https://www.cms.gov/About-CMS/Agency-Information/History/index.html?redirect=/History] From 2006 through 2014, spending for the program has grown 136 percent, from $51.3 billion to $121 billion. In 2014, the federal government allocated over $7 billion to coverage for controlled substances, including highly-addictive opioid drugs and narcotics intended to manage pain following surgery. Within this category, spending was highest for OxyContin, hydrocodone-acetaminophen, fentanyl, and morphine. The OIG further reports that spending within this limited category alone has grown 156 percent since 2006, a rate that outpaces the overall spending growth of the Part D program.

Aware of Medicare fraud? Contact a whistleblower attorney today.

If you are aware of possible prescription drug fraud within the Medicare or Medicaid program, do not hesitate to contact a whistleblower attorney about your information. For a confidential consultation, contact Berger & Montague, P.C. today!

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By | 2018-03-26T05:03:34+00:00 August 5th, 2015|Healthcare Fraud|