New Medicare Advantage policy to block prescriptions that compromise integrity of Medicare Part D

At Blue Cross Blue Shield of Michigan, we’re committed to protecting the integrity of our Medicare Part D program while ensuring the health and safety of our members. That’s why we’re implementing a new Medicare Advantage policy that will block the plan’s share of the cost of a member’s prescription when written by a provider who the plan determines is engaged in fraud, waste or abuse.

This policy doesn’t limit a provider’s ability to prescribe drugs; it simply requires that patients shoulder the entire cost of a drug if the prescription is written by a provider whose prescription has been blocked.

Currently, this policy applies to our commercial membership and is being expanded to include Medicare Advantage as well. In accordance with the policy, prescriptions written for Medicare Advantage members by providers who prescribe drugs that are neither medically necessary nor appropriate for the documented medical condition will no longer be payable. This directive becomes effective Feb. 1, 2016.

The policy specifies that if, at the time of dispensing, a provider is being investigated for fraud, waste or abuse — or was sanctioned by the Office of the Inspector General, the Government Services Agency, the Centers for Medicare & Medicaid Services or state licensing boards — the plan’s share of the prescription cost will no longer be payable.

If a provider is found to be subject to the policy’s prohibitions, Blue Cross will notify him or her. Additionally, in accordance with CMS regulations, physicians subject to the block will be given an appeal right before implementation. Blue Cross will also provide notice to affected members who receive prescriptions from sanctioned providers.

Following member and provider notification, Blue Cross will implement claims processing edits to reject all prescription claims submitted to a pharmacy for prescriptions written or ordered by a sanctioned provider. These claims will no longer be considered covered member services. The block will be effective for a period of five years.

If it’s determined that: the drugs aren’t medically necessary, may cause significant patient harm or aren’t appropriate for the documented medical condition(s), additional action may be taken, including:

• Case management
• Intervention by Pharmacy Services to institute quantity limits or other restrictions
• Preliminary investigation by Blue Cross Corporate and Financial Investigations and possible referrals 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

Before taking action under this new policy, Blue Cross will:

• Conduct an investigation and prepare a detailed findings report based on a review of the prescriber’s activity.
• Obtain an opinion from a Blue Cross medical consultant or contracted pain management consultant to confirm that the provider’s prescribing patterns aren’t medically necessary.
• Present findings and obtain approval for a Blue Cross provider sanction from Blue Cross executive leaders.
• Present the findings and approvals to the Audit Investigative Committee to gain approval to place a provider on Provider Prescription Block.
• The suspension of payments will be for a period of five years, as approved by the Audit Investigative Committee.
• The suspension will be effective 60 days after member notification.
• Members will be afforded a 60-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.
• A notice will be sent to the provider.
• The physician may appeal a suspension in writing to Blue Cross within 30 days of receipt of the notice.
• The written appeal will be reviewed by a panel of physicians. 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.
• If a provider’s appeal is unsuccessful, the provider may apply for reinstatement following the term of the prescription block.
• Blue Cross Pharmacy Services – Medicare will administer the Prescriber Prescription Block 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 won’t be reimbursed by Blue Cross.

Taking prompt action in situations where providers are prescribing large quantities of controlled substances helps ensure that group and member benefits are used in a way that complies with the terms of their coverage.

Reporting fraud

• To learn about reporting health care fraud, visit the “Report Fraud” section of the Blue Cross website.
• To report Medicare-related fraud, call our confidential, dedicated Medicare Anti-Fraud Hotline at 1-888-650-8136.
• To report Medicaid-related fraud, call 1-855-MI-FRAUD (643-7283) or visit michigan.gov/mdhhs.