Antiretroviral drugs, used to treat Human Immunodeficiency Virus (HIV), have recently come under scrutiny by the Office of Inspector General (OIG) as a target for fraud, waste and abuse.

According to the World Health Organization, in the year 2013 there were approximately 35 million people living with HIV, and an estimated 12 million HIV patients undergoing treatment with antiretroviral therapy. Antiretroviral drugs were first used to treat HIV in 1987, and today there are approximately 30 approved antiretroviral drugs. These drugs, frequently used in combination, have become increasingly effective in managing HIV. However, antiretroviral drugs come with high costs, with Medicare having paid $2.8 billion for HIV drugs in 2012.

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The high cost of HIV drugs has the potential to lead to abuse, with the OIG reviewing six measures from billed claims to identify questionable billing patterns among patients who received HIV drugs.

1. Patients with no current or historical diagnosis of HIV
2. Patients with no laboratory tests billed that are generally used to monitor the use of HIV drugs
3. Patients with no billed medical services from previous HIV prescribers
4. Patients receiving an excessive dose of an HIV drug (greater than 2 times the daily recommended dose)
5. Patients receiving an excessive supply of an HIV drug (more than 16-month or 480-day supply)
6. Patients receiving HIV drugs from a high number of pharmacies (6 or more pharmacies)

ICD-9-CM diagnosis codes monitored were:

-          042 (human immunodeficiency virus HIV-1 disease)

-          V08 (asymptomatic human immunodeficiency virus)

-          079.53 (HIV-2)

-          795.71 (nonspecific serologic evidence of human immunodeficiency virus)

OIG found that Medicare had paid $32 million for HIV drugs for patients that had questionable utilization patterns falling within these six measures. An example from the OIG report of a beneficiary with no indication of HIV diagnosis is the following:

“In 2012, Medicare paid $33,536 for HIV drugs for a 77-year old Detroit woman who had no indication of HIV in her Medicare claims history. She had prescriptions for 10 different types of HIV drugs prescribed by 6 different doctors. There is no evidence that she visited any of these doctors.”

Possible fraud schemes that would explain this example include the beneficiary diverting the drugs for sale on the black market, the pharmacy submitting claims for drugs never dispensed, or the beneficiary’s identification number having been stolen. All of these scenarios represent dollars lost to medical fraud. Payers can monitor claims for misuse of HIV drugs by comparing members’ prescription claims with billed medical claims for these measures.

Payers can also rely on Context 4 Healthcare's Fraud, Waste & Abuse solution. The Context⁴ Healthcare Fraud, Waste and Abuse (FWA) Module of FirstPass^TM starts with real-time claims analysis during the adjudication cycle, while you’re still calculating your claim liability. FirstPass^TM contains thousands of rules consisting of millions of editing combinations, many of which are designed to identify potential FWA conditions. Additionally, the rules include evaluation of billed charges against our proprietary national Usual, Customary & Reasonable (UCR) fee schedule to find claims with charges out of the national norm for a service. These claims are identified and brought to your attention for follow up. As claims are processed, the FirstPass^TM FWA Module ensures that claims meet one or more of our potential FWA rules and alerts your processors to the situation so further analysis and investigations can begin.

At Context, we analyze billions of claims each year, as part of this process we frequently find out-of-the-ordinary claim submissions that have potential for FWA activity. Utilization, regulatory, bundling, unbundling, and provider verification edits are some of the edit categories included in the FWA module.