September 22, 2010

(Washington, DC) — Pharmaceutical Care Management Association (PCMA) President and CEO Mark Merritt issued the following statement on new proposed regulations being released by the Centers for Medicare & Medicaid Services (CMS) that are designed to help prevent the $55 billion in improper payments made annually in Medicare and Medicaid. The new regulations come as the U.S. House Energy and Commerce Subcommittee on Health is holding a hearing today examining how to cut fraud, waste, and abuse in Medicare and Medicaid:

“Following the enactment of health reform, cost efficiency and program integrity are more important than ever. Preventing fraud, waste, and abuse is integral to these efforts and the new CMS proposals, especially new authority to suspend payments to providers suspected of fraud, are an important step in that direction.

“Pharmacy benefit managers (PBMs) agree that prevention, not ‘pay and chase’ is the key to fighting fraud. That’s why PBMs use a variety of state-of-the-art techniques to detect and prevent fraud, waste, and abuse before it happens. Unfortunately, some public policies undermine the fight against fraud by requiring payers to:

  • Include pharmacies in their networks that have been banned from federal programs (so-called ‘any-willing pharmacy’ policies);
  • Grant pharmacies that commit fraud a long waiting period before removing them from networks;
  • Grant pharmacies an advance notice ‘heads up’ before performing audits; and
  • Accelerate payments, leaving less time to detect and prevent fraudulent Medicare claims before payments are made (so-called ‘prompt pay’).”