“The Department of Health and Human Service Office of the Inspector General recently discovered widespread inappropriate access and use of Medicare beneficiary data by pharmacies and other healthcare providers.”
“HHS OIG released the findings of a longstanding audit conducted at the request of the Centers for Medicare and Medicaid Services. The aim was to assess mail-order pharmacy’s Medicaid Part D Eligibility Verification Transactions (E1 transactions), including provider transactions.”
“’Providers must use E1 transactions for their intended purposes, which include determining a beneficiary’s Medicare Part D coverage information to bill for a prescription or determining drug coverage billing order when the beneficiary is covered by more than one insurance plan,’ according to the report.”
“’Because E1 transactions contain beneficiary protected health information, we wanted to verify that the providers were using these E1 transactions for intended purposes,’ it continued…”
“OIG selected 30 providers to assess with 3.9 million submitted E1 transactions. They were chosen due to the large volume of transactions submitted compared with the number of processed prescriptions. They found that these providers were taking advantage of gaps in CMS program integrity in E1 transactions.”
“Specifically, 25 out of 30 providers used E1 transactions for a purpose other than billing for a prescription or determining drug coverage billing order. And 98 percent of these 25 providers’ E1 transactions were not associated with a prescription, on average…”
“OIG recommended CMS continue to monitor providers submitting a high number of E1 transactions relative to prescriptions process, in addition to the need to develop guidance for providers that clearly states E1 transactions shouldn’t be used for marketing purposes.”
“Further, CMS should ensure only pharmacies and other authorized entities submit E1 transactions, while taking appropriate enforcement action when abuse is discovered.”
“CMS concurred with the OIG recommendations and has already taken steps to reduce the number of inappropriate E1 transactions. In fact, since January 2019, CMS has rejected more than 250,000 E1 transactions from unauthorized entities…” Read the full article here.
Source: OIG Finds Serious Misuse of Medicare Data Transactions by Pharmacies – By Jessica Davis, February 18, 2020. Health IT Security.
