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July 25, 2022
Just Announced! CMS Announces Audits Targeting Fraud, Waste, and Abuse beginning October 2022
Beginning October 2022 and continuing throughout 2023, CMS - in conjunction with the Plan Program Integrity Medicare Drug Integrity Contract (PPI MEDIC) - will initiate three National Audits, six Self-Audits and four Program Integrity (PI) Audits. These audits are being conducted to evaluate plan sponsors’ efforts to detect, prevent and correct fraud waste and abuse (FWA).
National Audits that evaluate prescription drug event (PDE) data will focus on Transmucosal Immediate Release Fentanyl (TIRF) dugs (Part D covered for breakthrough cancer pain in opioid-tolerant patients), Targretin (Part D covered for primary cutaneous T-cell lymphoma, refractory to prior therapies), and Adcirca (Part D covered for pulmonary arterial hypertension (PAH)) as well as Revatio and Cialis (Part D covered for PAH and benign prostatic hyperplasia). The active ingredients of PAH drugs can also be found in drugs used for erectile dysfunction, a Part D excluded indication.
Self-Audits are focused on claims that crossover between Medicare Part C and Medicare Part D to ensure that these PDEs were correctly paid under Part D. CMS plans to target drugs provided to enrollees who have elected hospice. However, the scope of self-audits can be expanded at CMS’ discretion.
Finally, PI audits evaluate the plan sponsor’s efforts to address PI risks. CMS requires plan sponsors to have effective processes in place to detect, prevent, and correct FWA. With these PI audits, CMS plans to target FWA complaints, FWA referrals, FWA Requests for Information, Center for Program Integrity Audits, and Health Plan Management Systems (HPMS) memos.
The first audit will initiate in October 2022 with a national review of TIRF drugs. Plan sponsors should continue to monitor HPMS for additional information as well as potential selection for the audits.
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