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Volume XII, Number 267

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CMS Finalizes Program Changes for Medicare Advantage and Prescription Drug Benefit Programs - Alert!

  Not only are pharmacies and those who prescribe Part D drugs increasingly becoming targets for whistleblowers with False Claims Act suits for kickbacks and other fraud-based conduct, they also need to be concerned with Medicare Part D insurers, who monitor pharmacies for abuse On May 19, 2014, as well as CMS (Centers for Medicare & Medicaid Services) which issued a final rule revising the Medicare Advantage (MA) and Part D prescription drug benefit programs regulations for Contract Year 2015 (CMS-4159-F), aimed primarily at combating fraud and abuse in Part D.

Of significance is that the final regulation implements the Affordable Care Act requirement that MA plans and Part D sponsors actually report and return identified Medicare overpayments.  The provision codifies and clarifies rules regarding when Part D and MA plan sponsors must actually report and return overpayments.

The rule also expands health promotion and incentives for efficient use of health care resources and requires price transparency for Part D plans and network pharmacies.  Another provision requires that physicians, and other professionals who order durable medical equipment and supplies or certify home health care for beneficiaries, be enrolled in Medicare.  Such enrollment requirement can be extended to those who order covered Part D drugs, among other things.

Notably, the rule adds authority to revoke a physician’s or eligible professional’s Medicare enrollment under certain circumstances of abusive prescribing practices and patterns.  The focus of providing CMS the authority to revoke such prescribers’ Medicare enrollment is designed to help protect beneficiaries and the Medicare Trust Fund from fraud, waste and abuse.

Most of the provisions of the final rule will become effective for the 2015 contract year operations, and can be accessed in the full rule at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

Jackson Lewis P.C. © 2022National Law Review, Volume IV, Number 229
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About this Author

Nick Beerman, Employment and Labor Law, Shareholder Jackson Lewis
Shareholder

Nick M. Beermann is a Shareholder in the Seattle, Washington office of Jackson Lewis P.C.  Mr. Beermann practices in all areas of employment and labor law with emphasis in employment contracting and dispute resolution, corporate governance and internal investigations, Sarbanes-Oxley compliance and litigation, trade secret and non-competition advice and litigation, discrimination and harassment advice and litigation, ERISA litigation, OSHA investigations and charge resolution, business entity disputes, WARN advice, wage and hour compliance and...

206-405-0404
A. Patricia Diulus-Myers, Jackson Lewis, diversity initiatives lawyer, retention strategies attorney
Principal

A. Patricia Diulus-Myers is a Principal in the Pittsburgh, Pennsylvania, office of Jackson Lewis P.C. She was co-chair of the firm's Diversity Committee from 2005 through 2009. In this role she was responsible for identifying and leading the firm’s diversity initiatives throughout the country in support of recruitment and retention strategies.

Prior to joining Jackson Lewis, Ms. Diulus-Myers, a former registered nurse, worked with a corporate law firm and then served as Vice President and General Counsel for a hospital...

412-338-5141
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