OIG audits providers, finds improper use of Medicare Part D eligibility data

A recent audit conducted by the Office of Inspector General (OIG) found that the majority of healthcare providers reviewed used Medicare Part D eligibility information for potentially inappropriate purposes.

At the request of CMS, OIG audited 30 healthcare providers to check the use of their Medicare Part D Eligibility Verification Transactions (E1 transactions). Such transactions are intended to bill for a prescription or determine drug coverage billing order. Because the transactions contain beneficiaries’ protected health information (PHI), the audit was conducted to ensure providers were using the transactions for the intended purposes.

But the OIG determined that 25 of the 30 audited providers used the transactions for purposes other than billing for a prescription or determining drug coverage billing order. Additionally, 98 percent of the E1 transactions made by those 25 providers were not associated with a prescription, according to the OIG report.  

In total, OIG reviewed 3.9 million E1 transactions and found that 2.6 million did not match to a prescription.

In light of the findings, OIG recommended that CMS continue to monitor providers submitting a high number of E1 transactions relative to the number of prescriptions processed. OIG also advised CMS to publish guidance clearly stating that E1 transactions should not be used for marketing purposes. If abuse of E1 transactions persists, OIG recommended that CMS take appropriate enforcement action.