Medicare officials are seeking new authority to allow them to kick out physicians who engage in "abusive" prescribing practices, according to a newly released proposed rule.
The Centers for Medicare and Medicaid Services (CMS) issued a proposal Jan. 6 with several provisions aimed at rooting out fraud and abuse by physicians. The rule is part of a larger effort to identify Medicare beneficiaries who are potentially overusing opioids, as well as identify prescribers and pharmacies that may be involved in fraudulent activities.
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The rule is part of a larger effort to identify Medicare beneficiaries who are potentially overusing opioids, as well as identify prescribers and pharmacies that may be involved in fraudulent activities.
Beginning next year, the proposal would require Medicare Part D prescription drug plans to deny coverage for any drug claim that does not include a prescriber’s National Provider Identifier (NPI). Under the rule, physicians are not required to accept Medicare payments, but they must be enrolled in the program in an approved status or have a valid opt-out affidavit on file with the Medicare fee-for-service program.
The aim, according to CMS, is to ensure that anyone prescribing drugs to Medicare beneficiaries is properly qualified. The Affordable Care Act already requires physicians to be enrolled in the Medicare program for durable medical equipment, prosthetics, orthotics, and supplies, or if they certify home health care for Medicare beneficiaries.
Medicare officials also noted in the proposed rule that they want the right to revoke a physician’s Medicare enrollment if the physician exhibits a pattern of prescribing Part D drugs that is "abusive and represents a threat to the health and safety of Medicare beneficiaries." The agency also would be able to revoke Medicare enrollment if a physician’s Drug Enforcement Administration Certificate of Registration was suspended or revoked, or their state medical license was suspended or revoked.
The decision to revoke enrollment would only be made after a thorough and detailed investigation by CMS, according to the proposed rule.
"Honest physicians and eligible professionals who engage in reasonable prescribing activities would not be impacted by our proposal," the proposed rule states.
But the proposed rule does not define "abusive" or "threat to the health and safety of Medicare beneficiaries."
Instead, it includes a list of criteria for assessing prescribing practices:
• Are there diagnoses to support the indications for which the drugs were prescribed?
• Was the patient deceased or out of state at the time of an alleged office visit?
• Has the physician prescribed controlled substances in excessive dosages linked to patient overdoses?
• Has the physician been subject to disciplinary actions by the state medical board?
• Has the physician been sued for malpractice related to their drug prescribing and been found liable or paid a settlement?
• Has a public insurance program restricted or revoked the physician’s prescribing privileges?
Dr. Ardis Dee Hoven, president of the American Medical Association, said the organization has a zero tolerance policy for irresponsible prescribing that could harm patients and that the proposal is unlikely to affect physicians who are prescribing appropriately.
Dr. Ardis Dee Hoven
"The vast majority of physicians who appropriately and safely prescribe medications should not be targets of misguided government enforcement and driven out of practice," she said. "The AMA is carefully examining the details of the newly proposed rule to ensure the [CMS] does not compromise appropriate prescribing or exceed its statutory authority."
But CMS officials will need more data if they plan to identify fraud and abuse by physicians and beneficiaries. As a result, the agency is also proposing to collect information directly from pharmacy benefit managers, pharmacies, and others that contract with Part D drugs plans, rather than going through the drug plan for the information
The proposed rule will be published in the Federal Register on Jan. 10. The agency is accepting public comments at www.regulations.gov until March 7.