BCBSM to reject prescription drug claims when fraud, waste or abuse are indicated

Under a new Prescriber Prescription Block Policy, prescriptions written by a health care provider who prescribes drugs that are not medically necessary, may cause significant patient harm or are not appropriate for the documented medical condition will no longer be payable. This policy becomes effective Sept. 1, 2013.

In addition, if a provider is being investigated for fraud, waste or abuse — or has been sanctioned at the time the prescription is dispensed — the prescriptions he or she has written will no longer be payable. A sanctioned provider is one who has been sanctioned by the Office of the Inspector General, the Government Services Agency, the Centers for Medicare & Medicaid Services or state licensing boards.

BCBSM will notify sanctioned providers if they are subject to our Prescriber Prescription Block Program. BCBSM will also provide notice to affected members who have had a prescription written by the sanctioned provider within the past four months.

Following member and provider notification, BCBSM will implement claim processing changes to reject all prescription claims submitted to a pharmacy for prescriptions written or ordered by the provider. These claims will no longer be considered covered services for our members. The block will be effective for a period of five or more years.

If it is determined that the drugs are not medically necessary, may cause significant patient harm or are not appropriate for the documented medical conditions, additional action may be taken, including:

• Case management
• Intervention by Pharmacy Services to institute quantity limits or other restrictions
• Preliminary investigation by BCBSM Corporate and Financial Investigations and possible requests to law enforcement for an independent investigation to determine whether there is fraud, waste or abuse (Prosecution of the prescriber or member will be pursued through law enforcement when appropriate.)

Prior to taking action under this new policy, BCBSM will:

• Conduct an investigation and prepare a detailed report of findings that includes a 60-day review of the prescriber’s activity
• Obtain an opinion from a BCBSM medical consultant or contracted pain management consultant to confirm that the provider’s prescribing patterns do not appear to be medically necessary
• Present findings and obtain approval for a BCBSM provider sanction from BCBSM executive leaders
• Present the findings and approvals to the Audit Investigative Committee to gain approval to place a provider on Provider Prescription Block (issue a BCBSM provider sanction)
  • The suspension of payments will be for a period of five years as approved by the Audit Investigative Committee.
  • The suspension will be effective 30 days after member notification.
  • Members will be afforded a 30-day notice that prescriptions written by the prescriber will no longer be honored and that they may seek medical care from other providers for prescriptions deemed medically necessary for their health conditions.
  • Notice will be sent to the provider.
  • The provider may appeal a suspension in writing to BCBSM within 30 days of receipt of the notice.
  • The written appeal will be reviewed by the vice president of Pharmacy Services, a BCBSM medical director and a BCBSM attorney.
  • A decision regarding the provider appeal would then be rendered within 30 days of receipt of the appeal. The decision of the review panel will be final.
  • The appeal panel has the right to extend the effective date of the block if additional information is required by the panel.
  • If a provider appeal is unsuccessful, the provider may apply for reinstatement following the term of the prescription block.
• BCBSM Pharmacy Services will administer the Prescriber Prescription Block process in conjunction with its pharmacy benefit manager. Pharmacies will be notified via a fax-blast communication and will receive an electronic message indicating “Prescriber not covered” at the point-of-sale. The member may choose to pay for the prescription out-of-pocket, but the member will not be reimbursed by BCBSM.