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Medicare proposes rule to ban physicians who’ve prescribed criminally or abusively-Pro Publica

January 7, 2014

1/6/14, “In A Major Shift, Medicare Wants Power to Ban Harmful Prescribers,” Pro Publica, Weber and Ornstein

Medicare plans to arm itself with broad new powers to better control — and potentially ban — doctors engaged in fraudulent or harmful prescribing, following a series of articles by ProPublica detailing lax oversight in its drug program.

The U.S. Centers for Medicare and Medicaid Services (CMS) described the effort late Monday in what’s known as a proposed rule, the standard process by which federal agencies make significant changes.

Two of the changes mark a dramatic departure for the agency, which historically has given much higher priority to making medications easily accessible to seniors and the disabled than to weeding out dangerous providers.

For the first time, the agency would have the authority to kick out physicians and other providers who engage in abusive prescribing. It could also take such action if providers’ licenses have been suspended or revoked by state regulators or if they were restricted from prescribing painkillers and other controlled substances….

And the agency will tighten a loophole that has allowed doctors to prescribe to patients in the drug program, known as Part D, even when they were not officially enrolled with Medicare. Under the new rules, doctors and other providers must formally enroll if they want to write prescriptions to the 36 million people in Part D. This requires them to verify their credentials and disclose professional discipline and criminal history.

Currently, Medicare and the private insurers that run Part D know little about those writing the prescriptions — even those whose yearly tallies cost millions of dollars or who prescribe high volumes of inappropriate drugs.  ProPublica found that some of the doctors had been criminally charged or convicted, had lost medical licenses or had been terminated from state Medicaid programs serving the poor….

In interviews, many of the doctors said they had never been contacted by Medicare even though they agreed that their patterns were worthy of scrutiny….

The proposed rule also does not include other suggestions such as requiring diagnosis codes on prescriptions to assess their appropriateness or requiring private insurers in Part D to report suspected fraud, waste and abuse to Medicare’s fraud contractor. Such sharing is now voluntary….

In a blog post, Jon Blum, the principal deputy administrator for CMS, said his agency is serious about fighting fraud and abuse in Part D. Since 2011, he wrote, the agency has reduced the percentage of Part D patients who are potentially overusing painkillers and acetaminophen, which can cause severe liver damage in high doses….

But when ProPublica looked at the highest prescribers of narcotics in Part D, it found that many had faced criminal complaints, action by their state medical boards or other accusations of misconduct.”…

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