Managed Care

 

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

MANAGED CARE October 2009. © MediMedia USA
Editor's Memo

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

John Marcille
MANAGED CARE October 2009. ©MediMedia USA

John Marcille

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.

Meetings

Private Health Insurance Exchanges Conference Washington, D.C. October 7–8, 2014
National Healthcare Facility Management Summit Palm Beach, FL October 16–17, 2014
National Healthcare CFO Summit Las Vegas, NV October 19–21, 2014
National Healthcare CXO Summit Las Vegas, NV October 19–21, 2014
Innovative Member Engagement Operations For Health Plans Las Vegas, NV October 20–21, 2014
4th Partnering With ACOs Summit Los Angeles, CA October 27–28, 2014
2014 Annual HEDIS® and Star Ratings Symposium Nashville, TN November 3–4, 2014
PCMH & Shared Savings ACO Leadership Summit Nashville, TN November 3–4, 2014
World Orphan Drug Congress Europe 2014 Brussels, Belgium November 12–14, 2014
Medicare Risk Adjustment, Revenue Management, & Star Ratings Fort Lauderdale, FL November 12–14, 2014
Healthcare Chief Medical Officer Forum Alexandria, VA November 13–14, 2014
Home Care Leadership Summit Atlanta, GA November 17–18, 2014