Potential misclassifications reported by drug manufacturers may have led to $1 billion in lost Medicaid rebates
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report in brief
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, December 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Drug Costs Drug Industry -- economics Medicaid -- economics Pharmaceutical Preparations -- classification Pharmaceutical Preparations -- economics Insurance, Health, Reimbursement Insurance, Pharmaceutical Services Humans United States United States. Department of Health and Human Services. Centers for Medicare & Medicaid Services (U.S.)
- Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. Manufacturers with rebate agreements are required to report all of their covered outpatient drugs to the Medicaid Drug Rebate Program (Medicaid rebate program). The Centers for Medicare & Medicaid Services (CMS) calculates rebate amounts using manufacturer-reported pricing and classification data. Congress asked the Office of Inspector General (OIG) to evaluate the accuracy of manufacturer-reported data in the Medicaid rebate program, and CMS's oversight of that data. The Food and Drug Administration's (FDA's) marketing categories, which also are manufacturer-reported, can be used to help determine whether a drug is classified as an innovator, e.g., brand-name, or noninnovator, e.g., generic, product, for the purposes of calculating Medicaid rebates. Innovator products are generally subject to higher base rebate amounts. Manufacturers are required to pay an additional, inflation-adjusted rebate if a drug's price increases faster than inflation. When information provided by manufacturers is incorrect or missing, State Medicaid agencies may not be able to collect all appropriate rebates. How OIG Did This Review. We compared manufacturer-reported classifications for drugs in the Medicaid rebate program to drug information in FDA files. We determined the Medicaid drug classifications that matched FDA's, and those that did not match, i.e., were potentially misclassified, in 2016. We then estimated the rebate amounts that Medicaid may have lost from 2012 to 2016 for the 10 potentially-misclassified drugs with the highest total reimbursement in 2016. Finally, we reviewed CMS's policies and procedures for ensuring appropriate oversight of data submitted to the Medicaid rebate program. What OIG Found. The vast majority of the approximately 30,000 drugs in the Medicaid rebate program were classified appropriately. However, we found that manufacturers may have misclassified 885 of these drugs (3 percent) in 2016. We found that from 2012 to 2016, Medicaid may have lost $1.3 billion in base and inflation-adjusted rebates for 10 potentially-misclassified drugs with the highest total reimbursement in 2016. When CMS determines that information reported by manufacturers may be incorrect, it requests that manufacturers change the data. CMS does not have the explicit legal authority to require manufacturers to change their classification data. CMS did report that when it identifies potential errors in classification data, it works with manufacturers to assist them in correcting the errors. However, CMS does not track or maintain a central database of these potential errors or their resolutions. Therefore, we had no way to determine which drugs CMS identified as potentially-misclassified, or what steps, if any, CMS took to address these potential misclassifications. What OIG Recommends. We recommend that CMS (1) follow up with manufacturers associated with potentially-misclassified drugs identified in this report to determine whether current classifications are correct, (2) improve its Drug Data Reporting for Medicaid System to minimize inconsistent data submissions and track potential classification errors for followup, and (3) pursue a means to compel manufacturers to correct inaccurate classification data reported to the Medicaid rebate program. CMS concurred with all three recommendations.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (22 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101737986 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101737986