Fraud, Waste, and Abuse
The Medicare Modernization Act stated that all Part D plan sponsors are required to have in place a comprehensive fraud and abuse plan to detect, correct, and prevent fraud, waste, and abuse as an element of their compliance plan. Beginning with the 2009 plan year, CMS is mandating that plans incorporate fraud, waste, and abuse guidelines into their compliance plans and also requiring plans to apply their training requirements to all of their contracted entities, including pharmacies.
Specific instructions for how to implement a fraud, waste, and abuse program are left to the discretion of each sponsor. Therefore, there is some variation from plan to plan. However, each plan's requirements contain three basic elements:
For more information about CMS’ fraud, waste, and abuse requirements, visit www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/PDBManual_Chapter9_FWA.pdf.
First, pharmacies must have written policies and procedures that address fraud, waste, and abuse. These policies must be shared with all new employees and reviewed annually. Below are two products that can help pharmacies comply with this requirement.
» NCPA Employee Policy and Procedures Wizard v3.
» Medicare Part D Fraud, Waste, & Abuse Compliance Program
Pharmacies will need to document that pharmacy staff members have gone through fraud, waste, and abuse training. Below is one program that is recommended by several of the major Part D plans.
» LearnSomething
And finally, pharmacies will need to conduct background checks on all new employees using a federally-maintained database listed here and show documentation of those searches.
» http://exclusions.oig.hhs.gov/search.aspx
» https://www.epls.gov/
Additional Resources