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Medicare Part D Prescribers Must Act Now

On May 19, the Centers for Medicare & Medicaid Services (“CMS”) issued final regulations which require doctors prescribing drugs for Part D patients to enroll in Medicare. In addition, the regulations establish authority for CMS to revoke a doctor's Medicare eligibility for abusive prescribing practices, among other provisions. The regulations are part of the ongoing effort to curb fraud and abuse and to improve benefits and the quality of care for seniors and people with disabilities enrolled in these programs.

Last year, ProPublica (an independent nonprofit that produces investigative journalism) released a series of stories about Medicare’s failure to oversee its own drug program, Part D, effectively and created a public database of Part D records from 2007-2010. The searchable database consisted of physicians' identities and prescription patterns, prescription trends by state, top-prescribed drugs, and other Medicare Part D figures.

After the ProPublica information became public, the popular consensus was that Medicare Part D was overrun with rampant fraud, with doctors prescribing inappropriate or risky medications and Medicare wasting billions of dollars on needlessly expensive drugs. The database yielded several disconcerting statistics, including one that showed about 70 providers each churned out more than 50,000 prescriptions and refills, averaging at least 137 a day, in 2010.

Now, physicians and eligible professionals who prescribe covered Part D drugs must be enrolled in Medicare or have a valid record of opting out of Medicare in order for prescriptions to be covered under Part D. CMS now has the authority to revoke a physician’s or eligible professional’s enrollment in the program if it so determines that he or she “has a pattern or practice of prescribing that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.” Further, CMS may now revoke Medicare enrollment upon the suspension or revocation of a DEA registration or suspension or revocation of prescribing privileges from a state licensing board.

It is imperative that providers take the necessary steps now to enroll in Medicare or formally opt out in order to continue prescribing. The deadline is June 1, 2015. CMS projects it will save an estimated $1.615 billion over the next ten years thanks to new regulations.

If you are a Part D prescriber and have questions about applicable regulations, contact a McBrayer health care attorney today.

 Christopher J. Shaughnessy is an attorney at McBrayer, McGinnis, Leslie & Kirkland, PLLC.  Mr. Shaughnessy concentrates his practice area in health care law and is located in the firm’s Lexington office.  He can be reached at cshaughnessy@mmlk.com or at (859) 231-8780, ext. 1251. 

This article is intended as a summary of federal and state law activities and does not constitute legal advice.

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