In “Let the Crime Spree Begin,” NPR and ProPublica explore the vulnerabilities in Part D policy that allow elaborate fraud schemes to flourish. One major issue is timing- Part D requires insurance companies to pay for prescriptions within 14 days, a requirement passed by Congress in 2008 after pharmacies complained about payment delays. As a result, insurers must cover suspicious claims without thorough investigation.
Furthermore, insurers are not allowed to block claims from suspect prescribers and pharmacies. Only after a doctor is formally excluded from Medicare by the inspector general, a process that can take months and a conviction, will Part D stop covering his/her prescriptions. This “pay and chase” approach contrasts with the authority insurance companies have for non-Medicare plans to review prescriptions and take action against fraud.
NPR and ProPublica investigated several instances of fraud, some involving single doctors and others involving a network of doctors, pharmacists, and other medical professionals. Some doctors were the victims of identity theft and had no connection to the millions of dollars prescribed under their provider ID. In each instance, the huge increase in prescriptions written by these doctors should have warranted immediate investigation. Changes in policy that give insurance companies more power to address fraud, and more swift and decisive action from Medicare fraud officials could reduce the vulnerabilities in the system.