Department of Social Services Prescription Drug Oversight

Overall Conclusion

The audit found that while cost containment measures have contributed to reductions in prescription drug payments after 2015, significant control gaps remain, notably the absence of a comprehensive statewide PDMP and incomplete collection of National Drug Codes for physician-administered drug claims, which hinder rebates and federal reimbursement. In addition, the DSS did not fully prevent or recoup payments for excluded drugs, indicating a need to enhance MMIS controls and ensure compliance with federal requirements.

Source Document

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Audit Scope

Scope and Methodology: The audit covered the Department of Social Services (DSS) MO HealthNet Division, including Medicaid, CHIP, and MORx prescription drug oversight, with an emphasis on outpatient prescription drug payments for the year ended December 31, 2016. The review analyzed prescription drug claims processed through the Medicaid Management Information System (MMIS), with a focus on quarter ended December 31, 2016 due to data volume, while discussions and data references also cover broader trends from 2010 through 2017. The scope included analysis of cost trends, rebates, the drug utilization review process, the preferred drug listing and prior authorization, opioid monitoring programs (OPI), physician-administered drugs (including drugs billed with procedural codes), exclusions from Medicaid coverage, and PDMP status. The audit also included data matching against Missouri death records (2010-2016) to ensure deceased participants/providers were removed from eligibility, the lock-in program and related edits to ensure appropriate payment, and comparisons of prescriber/geographic patterns to identify potential abuse. The audit was conducted for the year ended December 31, 2016, with supplemental material and appendices referencing data through 2017.

Key Findings Summary

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2) Missouri does not have a comprehensive statewide prescription drug monitoring program (PDMP) for the Medicaid/CHIP programs; prior to July 2017 Missouri was the only state without a statewide PDMP; St. Louis County implemented a PDMP in March 2016, but it is not statewide and data is not utilized by DSS; CMS CMS guidance supports PDMP use for detecting fr…

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4) DSS controls were not sufficient to deny all drug claims for drugs excluded from Medicaid; 56 claims totaling $5,170 paid in Q4 2016 for drugs excluded from coverage (including fertility, sexual dysfunction, weight loss, hair growth, etc.); the department had a manual process to turn off NDCs but may have missed these drugs; recommendations include recoup…

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1) The Missouri Department of Social Services (DSS) relies on Medicaid, CHIP and MORx to pay for outpatient prescription drugs, with total prescription drug payments totaling about $959 million in 2016; costs decreased after peaking in 2015, with 2016 and 2017 showing declines, and cost containment measures (generic incentives, claims edits to favor lower-co…

View the Findings tab to see all 4 findings

AI-Assisted

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AI Scope Summary

Assess internal controls and compliance related to prescription drug payments for Medicaid/CHIP/MORx; evaluate cost containment effectiveness; review monitoring programs like PDMP; and examine excluded and physician-administered drug claims.

AI-Generated Insight

Missouri’s Prescription Drug Oversight audit highlights progress in cost containment for Medicaid/CHIP MORx spending through generic incentives, system edits, and rebates, but also reveals critical gaps in program integrity: the lack of a statewide PDMP and underutilization of PDMP data, missing NDC data on physician-administered claims leading to unbilled rebates and noncompliant costs, and insufficient controls to prevent or recoup payments for excluded drugs. The findings underscore urgent opportunities to strengthen governance, data integration, and federal-reimbursement compliance, which could improve patient safety, reduce waste, and maximize federal funding.

Audit Objectives

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Evaluate internal controls over significant management and financial functions as they relate to oversight of prescription drugs.

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Evaluate compliance with certain legal provisions as they relate to oversight of prescription drugs.

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Evaluate the economy and efficiency of certain management practices and information system control activities as they relate of oversight of prescription drugs.

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Analyze prescription drug cost trends and evaluate the effectiveness of cost containment procedures.

Audit Findings (4)

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2) Missouri does not have a comprehensive statewide prescription drug monitoring program (PDMP) for the Medicaid/CHIP programs; prior to July 2017 Missouri was the only state without a statewide PDMP; St. Louis County implemented a PDMP in March 2016, but it is not statewide and data is not utilized by DSS; CMS CMS guidance supports PDMP use for detecting fraud/abuse.

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4) DSS controls were not sufficient to deny all drug claims for drugs excluded from Medicaid; 56 claims totaling $5,170 paid in Q4 2016 for drugs excluded from coverage (including fertility, sexual dysfunction, weight loss, hair growth, etc.); the department had a manual process to turn off NDCs but may have missed these drugs; recommendations include recouping noncompliant payments and enforcing prior authorizations for excluded drugs.

3

1) The Missouri Department of Social Services (DSS) relies on Medicaid, CHIP and MORx to pay for outpatient prescription drugs, with total prescription drug payments totaling about $959 million in 2016; costs decreased after peaking in 2015, with 2016 and 2017 showing declines, and cost containment measures (generic incentives, claims edits to favor lower-cost drugs, and pursuing supplemental rebates) being used to manage costs.

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3) The DSS lacked system controls to require collection of national drug codes (NDCs) for all physician-administered drug claims, limiting the ability to bill manufacturers for rebates; about $170,000 in physician-administered drug claims were paid in 2016 as procedural claims lacking NDCs, and DSS did not recoup these improper payments or reimburse the DHHS for noncompliant costs.

Recommendations (0)

No recommendations provided for this audit