Prescriptive Authority: Who’s got it, and who doesn’t

Hot on the heels of the OIG’s unflattering report detailing the inadequacies of NPPES and PECOS, the OIG released another report skewering the performance of part D plan sponsors verification of prescriptive authority for prescribers. A study of prescriptions in 2009 highlighted the need for increased oversight on part D prescriptions. Having revealed more than $50 million in improper PDE claims paid, the OIG is now calling for more scrutiny on prescribers and prescriptive patterns. The report highlights the need for plan sponsors to have reliable prescriber controls in place to avert improper claims payments. This will require systems to enable proactive management of these issues. While some plan sponsors have taken steps to heighten verification efforts, not everyone is in this position.

When the OIG looked at 14 “obvious” non-prescriber types accounting for over 70,000 prescriptions, some interesting anomalies were found:

  • An interpreter ordered 1,210 prescriptions
  • A contractor ordered 79 schedule II drugs (commonly abused painkillers)
  • A counselor ordered 174 Schedule II drugs for just 13 beneficiaries
  • And the list goes on…

The OIG study identified troubling numbers of inappropriate prescriptions in a subset of just 10 states accounting for 53% of Medicare payments:

Selected as Prescriber Types Without the Authority to Prescribe in 10 States, 2009

Even more troubling were the types of practitioners and the rate at which Medicare paid them for prescriptions they had no authority to issue:

Selected as Prescriber Types Without the Authority to Prescribe in 10 States, 2009

Although the recent study results will certainly bring attention to payments and likely drive increasing audit actions, CMS already has a policy that recommends “sponsors develop indicators and establish baseline data so that they can recognize abnormalities and changes in prescribing patterns”. This suggests sponsors should currently have a reference source that indicates the practitioner type of a prescriber so individuals without prescribing authority can be identified. 

These challenges are not insurmountable. At a high level, Health Market Science divides our Provider MasterFile™ file into 18 different practitioner types which can be used to identify prescribers and their prescriptive authority:  

Health Market Science Practitioner Types*denotes general prescribing rights


Health Market Science also has complete data on 130 different state license credentials, an area where prescriber verification becomes even more complex.  Our research has shown there are certain license credentials that have prescribing rights in some states, but not in all.  For example, in a handful of states, pharmacists may have prescriptive authority.  Psychologists also have limited prescribing rights in some states.  Thus, a state by state grid of license credentials is required to ensure adherence to each states’ rules.

All of OIG’s recommendations suggest that this effort requires an accurate source of provider data and steps to ensure:

  • Sponsors comply with the requirement to verify that prescribers have the authority to prescriber drugs
  • Medicare Drug Integrity Contractor (MEDICs) increase monitoring of prescribers (“instructed Medics to do more proactive data analysis”)
  • Medicare does not pay for prescriptions from individuals without prescribing authority
  • Follow-up on individuals without authority who ordered prescriptions

Given CMS concurrence with the recommendations, it is only a matter of time before they provide guidance in an upcoming call letter and begin more aggressively enforcing these requirements.  There is no doubt this is coming, the only question is when the responsibility and costly implications will be pushed from plan sponsors to pharmacies.

Special thanks to our intern, Monica Reichert, for her help researching this subject and the pharmacy industry.