This month the Centers for Medicare and Medicaid Services (CMS) issued final regulations for the Medicare Advantage and prescription drug benefit (Part D) programs. The proposed new requirements largely aim to improve the integrity and efficiency of Medicare Part C and Part D, the prescription drug program. CMS projects that the rule will save an estimated $1.615 billion over the next ten years 2015-2024.  

After receiving more than 7,500 public comments on the proposed rule, new provisions include

• Expanded efforts to improve payment accuracy and efficiency;
• Require Part D plans and their pharmacy benefit managers to make reimbursement rates for certain drugs available to contracted pharmacies; and
• Require Medicare Advantage plans and Part D sponsors to report and return Medicare overpayments.

CMS will be expanding program integrity efforts, to include requirements that increase transparency and information flow within Medicare communities. For example, the rule broadens the release of unencrypted prescriber, plan, and pharmacy data to researchers. Additionally, CMS will allow its antifraud contractors to directly request and collect information from pharmacies that contract with Part D sponsors.

Furthermore, CMS hopes to reduce fraud and abuse by requiring prescribers of Part D drugs to enroll in Medicare to ensure that only qualified professionals can issue drug prescriptions. Once enrolled, if a physician or eligible professional demonstrates prescription abuse, the prescriber could face having his or her Medicare enrollment revoked.  

Thanks to Bill Finerfrock, Matt Reiter, Lara Burt, Cassy Perkins and Carolyn Bounds for contributing this article.