December 16, 2009 Via Electronic Transmission The Honorable Kathleen Sebelius Secretary U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 Charlene Frizzera Acting Administrator Centers for Medicare and Medicaid Services U.S. Department of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 Dear Secretary Sebelius and Acting Administrator Frizzera: The United States Senate Committee on Finance (Committee) has jurisdiction over the Medicare and Medicaid programs. As the Ranking Member of the Committee, I have a responsibility to protect these programs and the more than 100 million beneficiaries who receive health care through them. The overutilization of health services and healthcare fraud play a significant role in the rising cost of our healthcare system. I write today to learn more about how the U.S. Department of Health and Human Services (Department) and the Centers for Medicare and Medicaid Services (CMS) monitor the activities of providers when rates of utilization appear to be significant outliers. I have come into possession of documents provided by the Florida Agency for Health Care Administration identifying the state's top Medicaid prescribers of mental health drugs. This list, which is attached for your convenience, takes into account all prescriptions written in the Medicaid program during the second half of 2007, all of 2008, and the first quarter of 2009. I note with alarm that the top Medicaid prescriber during that time wrote 96,685 prescriptions for mental health drugs - nearly twice the number written by the second-highest prescriber. That means that this physician wrote approximately 153 prescriptions each and every day, assuming he did not take vacations. On the basis of these facts, please answer the following questions: 1) What systems does the Department have in place to monitor utilization rates across the country? This should include: a. Whether the Department tracks prescriber data such as that included above. b. If so, do the numbers above match your data? c. If you do not track such data, why not? 2) Please provide a list detailing overutilization allegations and investigations received or conducted by the Department since 2007. 3) When the Department discovers that a provider is an outlier in his or her utilization rates, what steps are taken? a. What threshold must be met before the Department takes additional steps? b. When that threshold is met, is the provider in question subject to any additional scrutiny or site visits? 4) Has the Department received allegations or information relating to possible overutilization by the provider described above? 5) What information do states share with the Department regarding Medicaid providers, allegations of overutilization, or enforcement actions? a. Do enforcement actions by the state trigger similar actions at the federal level? b. If so, what actions are triggered? I thank you in advance for your cooperation and request that you provide the requested documents and written responses by no later than January 8, 2009. All formal correspondence should be sent electronically in PDF format to Brian_Downey@financerep.senate.gov or via facsimile to (202) 228-2131. Of course should you wish to discuss this matter further, please do not hesitate to contact Christopher Armstrong of my Committee staff at (202) 224-4515. Sincerely, Charles E. Grassley Ranking Member cc: The Honorable Daniel R. Levinson Inspector General U.S. Department of Health and Human Services Office of Inspector General 330 Independence Avenue, SW Washington, DC 20201 Enclosure 2 Table 1: MDTMP Top Single Prescribers Ranked by Total_RXs Q3-2007 thru Q1-2009 Total_#_of_ Mental_Health_Rx 96685 53018 48527 33610 32518 32219 27763 26976 25898 24771 23855 23702 23025 22363 22338 21912 21793 21771 21570 21372 19084 18350 18096 17566 17348 16512 16373 16241 15746 15516 15508 15290 15022 15012 14972 14970 14820 14775 14444 14023 13890 13651 13236 13227 13160 12874 12815 12706 12676 Total_#_of_Rx_ to_Meet_CCI 1533 1845 573 1389 2346 1358 284 1202 1006 791 894 587 329 1253 3379 938 488 1621 1160 428 372 1313 629 908 885 2392 1435 757 232 180 654 1147 462 649 515 386 661 378 1082 504 158 297 141 256 372 66 311 798 472 . Pct_Edit_Total 1.6 3.5 1.2 4.1 7.2 4.2 1.0 4.5 3.9 3.2 3.7 2.5 1.4 5.6 15.1 4.3 2.2 7.4 5.4 2.0 1.9 7.2 3.5 5.2 5.1 14.5 8.8 4.7 1.5 1.2 4.2 7.5 3.1 4.3 3.4 2.6 4.5 2.6 7.5 3.6 1.1 2.2 1.1 1.9 2.8 .5 2.4 6.3 3.7 Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 FERNANDO MENDEZ-VILLAMIL HUBERTO MERAYO ANTONIO TAULER VIDAL LOPEZ JORGE BETANCOURT ALFREDO PINIELLA ALFREDO PUJOL FAY CANNON FADI SABA UMESH MHATRE JUNIOR PITTACK BEATRIZ GRISOLIA NELSON HERNANDEZ JORGE BENITO FRANCISCO PAGES JOSE GAMEZ ORLANDO SANTANA STEVEN KAPLAN KATINA MATTHEWS-FERRARI LUIS GUERRERO GINETTE DIEDERICH CARLOS DANGER BRIAN JOSEPH LINDA LEFLER JOSE CRUZ ABRAHAM FLEMENBAUM MARIO CUERVO NOAH JEANNETTE ANAIMALAI NANJUNDASAMY LAURENCE PETTY STEVEN SPEISER WOMESH SAHADEO SIKANDAR KHAN JOSE ADAN GUIDO LUDERGNANI JORGE DORTA-DUQUE PEDRO RODRIGUEZ JUAN ORTIZ GABRIEL DE CANDIDO JAMES ZENEL UNKNOWN CESARE RZADKOWOLSKY-RAOLI VINCENT DILELLA PRISCILLA BORREGO SARAH FRAZIER KENNETH BERDICK HENRY DUMAS SANTIAGO DE LOS ANGELES REX BIRKMIRE Prescriber_ID ME0075685 ME0038613 ME0065292 ME0014047 ME0041415 ME0070852 ME0044805 ME0059147 ME0071448 ME0027561 ME0089943 ME0043385 ME0061921 ME0062660 ME0036112 ME0057127 ME0082548 ME0046745 ME0052933 ME0065537 ME0044238 ME0090775 ME0086501 ME0050988 ME0090082 ME0025377 ME0040730 OS0009252 ME0079083 ME0068819 ME0038964 ME0050472 ME0069108 ME0066403 ME0096862 ME0056882 ME0028664 ME0026252 ME0039740 ME0055998 1578605614 ME0060415 OS0006347 ME0065158 ME0083534 ME0017772 ME0026677 ME0065644 ME0075680 Page 1