Managed Care

CMS is pleased to release the final chapter for the Prescription Drug Benefit Manual regarding a program to control fraud, waste and abuse. CMS thoughtfully considered each of the comments we received to the draft chapter released on February 8, 2006. This chapter provides both interpretive rules and guidelines for Part D plan sponsors on how to implement the regulatory requirements under 42 C.F.R. § 423.504(b)(4)(vi)(H) to have in place a comprehensive fraud and abuse plan to detect, correct and prevent fraud, waste and abuse as an element of their compliance plan. While CMS regulations require Sponsors to implement a comprehensive fraud and abuse program, the adoption of the methods suggested within this chapter on how to implement a comprehensive fraud and abuse program are left to the discretion of each Sponsor. Additionally, this chapter outlines CMS’ guidelines for operational issues such as handling complaints, and coordinating with CMS and law enforcement.

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