5 geographic hotspots for questionable dispensing

July 16, 2015

One way that the government targets fraud and abuse in Medicare Part D is by identifying areas where its payments per beneficiary for certain drugs are significantly higher than the average payments nationwide.

One way that the government targets fraud and abuse in Medicare Part D is by identifying geographic areas where its payments per beneficiary for certain drugs are significantly higher than the average payments nationwide.

A recent report by the Department of Health & Human Services’ Office of the Inspector General (OIG) identified five geographic hotspots for certain drugs that point to possible fraud and abuse.

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“The billing patterns in hotspots raise questions about whether these drugs were medically necessary or were actually provided to beneficiaries. Also, because some of these drugs are available as generics or over the counter, there are questions about whether pharmacies are billing for the higher priced brand-name drug but providing a less expensive drug,” the report read. “Although medical need and prescriber practices may vary across different areas of the country, the patterns in these hotspots warrant further scrutiny, as they may indicate fraud and abuse.”

Follow the links below to see which geographic areas have raised red flags at the OIG.

 

 

 

 

 

 

San Juan, Puerto Rico, apparently, is not only known for beaches and watersports. OIG has flagged it as a hotspot for diclofenac potassium, an anti-inflammatory used for rheumatoid arthritis and osteoarthritis.

See also: More Rx-to-OTC switches on the horizon?

Last year, one out of six Medicare beneficiaries in San Juan received diclofenac potassium. Nationwide, one out of 250 Medicare beneficiaries received this drug in 2014. Nearly one-third of all Medicare payments for diclofenac potassium in 2014 went to San Juan.

 

 

 

 

According to OIG, McAllen, Texas is a hotspot for Nexium, the proton pump inhibitor used to treat gastroesophageal reflux disease. This drug is available in an over-the-counter version.

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In McAllen, 17% of Medicare beneficiaries received prescription Nexium in 2014. Nationwide, a mere 4% of Medicare beneficiaries received prescription Nexium last year. In 2014, Medicare paid $20 million for Nexium for McAllen beneficiaries.

 

 

 

 

Miami is a hotspot for beaches, nightclubs, and Solaraze, the brand-name ointment used to treat skin lesions resulting from sun damage. A generic version of this ointment is available.

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Last year, the average Medicare payments per beneficiary for Solaraze were more than four times higher in Miami than the national average. In 2014, three-quarters of all Medicare payments for Solaraze went to Miami, New York, and Los Angeles.

Image credit: Image © avNY, Shutterstock.com

 

 

 

 

If it were not for Los Angeles (where OIG has identified similar, problematic dispensing patterns), New York City would be the nation’s capitol for questionable dispensing.

See also: Feds targeting Indiana pill mill doctors, pharmacists

OIG has identified the Big Apple as a geographic hotspot for Solaraze, Vascepa, Lovaza, and Lidoderm dispensing. In New York, the average Medicare payments per beneficiary for Solaraze were almost 9 times higher than the national average. In 2014, half of all payments for Solaraze nationwide went to New York.

New York is also a geographic hotspot for both Vascepa and Lovaza, omega-3 fatty acids used to help reduce high triglyceride levels and which are available as OTC supplements.

In 2014, the average Medicare payments per beneficiary for Vascepa were nearly triple the national average in New York. For Lovaza, the average Medicare payments per beneficiary in New York were three times the national average.

New York is also a geographic hotspot for Lidoderm, the anesthetic patch used to relieve pain caused by shingles. According to OIG, average Medicare payments per beneficiary for Lidoderm in 2014 were three times higher than the national average in New York.

Image credit: Image © avNY, Shutterstock.com

 

 

 

 

 

The OIG report identified the City of Angels as a geographic hotspot for Solaraze, Vascepa, Lovaza, and Lidoderm dispensing. In Los Angeles, the average Medicare payments per beneficiary for Solaraze were more than four times higher than the national average in 2014.

See also: Lawmaker’s pharmacy license yanked for writing fake Rxs

For Vascepa, the average Medicare payments per beneficiary were more than seven times the national average in Los Angeles. For Lovaza, the average Medicare payments per beneficiary in Los Angeles were three times the national average.

Los Angeles and New York were responsible for $96 million in Medicare payments for Lovaza in 2014, one-third of all Medicare payments for the drug last year.

Last year, average Medicare payments per beneficiary for Lidoderm were four times higher than the national average in Los Angeles. In 2014, one-third of all Medicare payments for Lidoderm ($113 million) went to beneficiaries in New York and Los Angeles.  

Image credit: Image © avNY, Shutterstock.com