Medicare Part D Drug Plans Can Withhold Payments on Suspicious Claims

In a growing effort to prevent “doctor shopping,” Medicare Part D prescription drug plan sponsors can now safely withhold pharmacy payments on suspicious claims without violating prompt payment requirements.  A recent CMS Notice clarifies that when a sponsor suspects fraud with respect to a particular claim, payment need not be made until the claim has been investigated further to determine that it is not fraudulent.  The Notice reflects an increasing trend of moving away from anti-fraud policies that inadvertently require sponsors to “pay and chase” claims believed to be fraudulent and instead moving towards policies that prevent the payment in the first place.

The CMS Notice can be read at: Clarification of Medicare Part D Policies with Respect to Overutilization.

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