NCPA Responds to Report on Questionable Medicare Pharmacy Billing

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Alexandria, Va. - May 10, 2012 In response to a report issued today by the U.S. Department of Health and Human Services Office of the Inspector General (OIG) entitled "Retail Pharmacies with Questionable Part D Billing", National Community Pharmacists Association (NCPA) CEO B. Douglas Hoey, RPh, MBA issued the following statement:

"Independent community pharmacists believe there is no place for fraud in Medicare or any other health program. While we are still reviewing the Inspector General's report and recommendations, community pharmacists look forward to continuing to work with Medicare, Congress and health plans on appropriate steps to protect against fraud, while preserving seniors' access to lifesaving medications and face-to-face counseling on their proper use. We believe overall health care costs have been reduced by the efforts of community pharmacists working with patients to maximize the benefits of medication therapy and to avoid costlier medical procedures and complications.

"It is important to note that for approximately 96 percent of community pharmacies the OIG report identified no 'questionable' billing. Regarding the small percentage of pharmacies that the OIG report focuses on, it lacks sufficient detail to evaluate the medical legitimacy and appropriateness of the claims reviewed.

"As OIG itself notes throughout its report, there could very well be legitimate medical reasons behind many of the claims it has flagged. For example, independent pharmacies serve a disproportionately high number of long-term care and other patients who are prescribed more medications than the average Medicare beneficiary. In addition, independent pharmacies are often in underserved, rural areas and OIG noted that such pharmacies have few physicians nearby and 'may bill for an extremely high average number of prescriptions per prescriber.' Moreover, many independents are in urban areas near large teaching hospitals or cancer clinics where physicians prescribe a disproportionate share of controlled substances. It is also true that, in the past, some apparent fly-by-night Medicare fraudsters have either misrepresented themselves as 'independent pharmacies', or been characterized that way, when legitimate pharmacists and most consumers would not consider them as such.

"From the community pharmacist's perspective, what's needed in terms of fraud protection efforts is for both Medicare and private health plans to work smarter and more efficiently. Already, independent community pharmacists struggle to comply with a wide array of inconsistent oversight and auditing requirements. Pharmacists who provide the right medication to the right patient at the right time, as prescribed by a physician, are routinely fined severely by health plans over trivial clerical issues. That scenario leaves pharmacists with less time to counsel patients and drives up the pharmacy's costs - without addressing true fraud. Such audits of pharmacies are already in place. However, there is not clarity on whether recouped funds are passed on to plan sponsors and patients or retained by the auditors and middlemen. To bring standards, clarity and consistency to pharmacy audit practices, NCPA supports state and federal reform legislation, including H.R. 4215, the Medicare Pharmacy Transparency and Fair Auditing Act.

"In responding to the OIG report, policymakers should proceed carefully to get at the heart of the issue without inadvertently burying pharmacists and patients in unproductive red tape."

The National Community Pharmacists Association (NCPA®) represents the interests of America's community pharmacists, including the owners of more than 23,000 independent community pharmacies. Together they represent a $93 billion health care marketplace, dispense nearly 40% of all retail prescriptions, and employ more than 315,000 people, including 62,400 pharmacists. Independent community pharmacists are readily accessible medication experts who can help lower health care spending. They are committed to maximizing the appropriate use of lower-cost generic drugs and reducing the estimated $290 billion that is wasted annually by improper medication use. To learn more go to or read NCPA's blog, The Dose, at

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