PCMA: New Law Ending Immediate Payment for Unverified Claims in Medicare a Step in the Right Direction

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harmaceutical Care Management Association (PCMA) President and CEO Mark Merritt issued the following statement on a new anti-fraud law that would hasten an end to Medicare’s policy of paying questionable fee-for-service claims quickly without verifying them.

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This new law to suspend payments and review potentially fraudulent, unverified claims underscores the increased focus on fighting fraud, waste, and abuse in Medicare and is a step in the right direction.

Pharmaceutical Care Management Association (PCMA) President and CEO Mark Merritt issued the following statement on a new anti-fraud law that would hasten an end to Medicare’s policy of paying questionable fee-for-service claims quickly without verifying them:

“This new law to suspend payments and review potentially fraudulent, unverified claims underscores the increased focus on fighting fraud, waste, and abuse in Medicare and is a step in the right direction. As CMS and others have noted, it’s far easier to prevent fraud than to engage in ‘pay and chase’ activities after the fact.

“Unfortunately, other public policies still discourage payers from doing everything possible to curb fraudulent behavior, including:

  •     So-called ‘prompt pay’ laws in Medicare Part D which reduce the time available to detect pharmacy fraud, waste, and abuse;
  •     Requirements that payers include in their networks pharmacies that have been banned from federal programs (so-called ‘any-willing pharmacy’ policies);
  •     Granting pharmacies that commit fraud a long waiting period before removing them from networks; and
  •     Granting pharmacies an advance notice ‘heads up’ before performing audits.”

PCMA represents the nation’s pharmacy benefit managers (PBMs), which improve affordability and quality of care through the use of electronic prescribing (e-prescribing), generic alternatives, mail-service pharmacies, and other innovative tools for 210-plus million Americans.

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Contact:         
Charles Coté, 202-207-3605

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