Benefit Integrity Medicare Drug Integrity Contractor (BI MEDIC): Health Integrity, LLC

1. Benefit Integrity Medicare Drug Integrity Contractor (BI MEDIC): Health Integrity, LLC Tasha Trusty, RN BI MEDIC, Nurse Investigator Manager

2. MEDIC Purpose and Goals To assist the Centers for Medicare & Medicaid Services (CMS) in protecting the integrity of the Medicare Parts C and D programs by accomplishing the following objectives: • Identify and prevent Medicare Parts C and D fraud, waste, and abuse, and refer instances to the appropriate law enforcement (LE) agency • Support ongoing LE investigations by responding to requests for information • Perform data analysis efficiently and proactively to evaluate inappropriate activity • Assist with audits as needed • Educate the public about MEDIC responsibilities and ways of protecting themselves and the Medicare program from fraud • Monitor inappropriate agent/broker activities and interface with the Department of Insurance

3. STOP Non-Compliance And FWA Help Us Help You in the Fight

4. Who Commits Fraud, Waste, and Abuse? • Plans Sponsors and Pharmacy Benefit Managers • Pharmacies • Prescribers/Physicians • Opportunists and Beneficiaries

5. Plan Sponsors and Pharmacy Benefit Managers • Inappropriate enrollment/disenrollment • Inaccurate data submission • Adverse selection • Retain health members • “Cherry picking” or the exclusion of certain groups from services • TrOOP manipulation • Prescription drug switching • Inappropriate formulary decisions • Fictitious employees or members • Payments for deceased members

6. Plan Sponsors and Pharmacy Benefit Managers (continued) • Under-utilization and denial of necessary covered medical care • Bonus pools or withholding fees based on service utilization • Misrepresentation of the plan • Physician to patient ratio • Physician qualifications • Access to care • Fraudulent subcontracts • Inappropriate financial incentives paid to facilities or beneficiaries to obtain enrollments

7. Pharmacies • There are three kinds of pharmacies: retail, mail order, and long-term care • Prescription drug shorting • Dispensing expired or adulterated prescription drugs • Prescription forging or altering • Signature logs • Prior authorization forms • Prescriptions • Inappropriate billing practices • Billing for brand names when generics are dispensed • Billing for covered drugs when non-covered drugs are dispensed • Billing for non-existent prescriptions • Charging retail vs. negotiated price

8. Prescribers/Physicians • Bill for services that are not medically necessary • Bill for services not rendered • Provision of false information • Theft of prescriber’s Drug Enforcement Agency (DEA) number or prescription pad • Prescription drug switching • Script mills

9. Opportunists and Beneficiaries • Elderly beneficiaries • 65+ • Young beneficiaries • Under the age of 65 • Disabled/ESRD • Relatives/friends of beneficiaries • Pick up prescription drugs at pharmacies • Steal prescription drugs from medicine cabinets • Identity theft/fraud • Beneficiary representing themselves as physician/clinic staff • Beneficiary representing themselves as another beneficiary • Beneficiary allowing someone else to use their benefits

10. Opportunists and Beneficiaries (continued) • Doctor shopping and pharmacy shopping • Multiple prescribers • Multiple pharmacies • Overlapping days supply • Prescription forging or altering • E-prescription and tamper-proof pads are being utilized to deter this activity • Resale of drugs on black market • Multiple scripts for narcotics or other drugs sold on the street/black market

11. Complaints Not Handled by the MEDIC • Customer service issues with Plan Sponsors • Enrollment, disenrollment and premiums • TrOOP calculations • Formulary issues • Established appeals or grievances with Plan Sponsors • Beneficiaries seeking reimbursement from Plan Sponsors • Low Income eligibility/status • Customer service issues may persist and accumulate to form compliance issues • Fee For Service (FFS) or Original Medicare (Medicare Part A, Part B, DME, Home Health and Hospice) fraud, waste, and abuse • Some overlap can occur, especially if there is a concern that drugs are being inappropriately billed to Part B or Part D

12. Complaint Referrals to the MEDIC • The content of the complaint should be: • Clear • Without acronyms • Non-judgmental • Factual • Have supporting documents such as the complaint, Plan Sponsor statements, notes, records, discussions with complainant, provider or beneficiary • Utilize SMART FACTS to refer complaints whenever available to you

13. MEDIC Contact Information BI MEDIC: Health Integrity, LLC By phone: 877-7SAFERX (877-772-3379) By fax: 410-819-8698 In writing: Health Integrity Attention: MEDIC 9240 Centreville Road Easton, MD 21601

14. Questions and Answers