The City of Toronto’s auditor general is raising yet more concerns about benefits fraud after discovering employees may have shopped around for doctors to get prescriptions for excessive amounts of erectile dysfunction drugs.
In an update this month to her October 2016 report on potentially excessive and unusual drug claims by employees to the city’s benefits plan, Beverly Romeo-Beehler found 10 claimants appeared to have shopped around for on-demand erectile dysfunction drugs. One employee received $15,300 in reimbursements over three years for erectile dysfunction drugs, using a different physician and pharmacy almost every time.
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During the first phase of the report, the auditor general wasn’t able to access claim files or information maintained by the city’s insurer at the time. The updated report includes additional information, such as physician identification numbers. It also has details from a sample of claims on the the number of days’ supply for the drugs dispensed.
The report noted the city covered about $1.9 million for erectile dysfunction drugs in 2015. “However, the city’s benefits plans have no limit on erectile dysfunction drugs, which exposes it to unnecessary financial risk and risk of benefits abuse by a small number of plan members,” wrote Romeo-Beehler.
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Other issues raised in the report include:
- The reimbursement of 69 over-the-counter drugs that didn’t appear to have a life-sustaining purpose, despite the fact the city’s plan covers certain products only for that situation. The report highlighted the need for the city to develop a formal approval process for granting benefits exceptions.
- While the majority of drugs are subject to a $9 maximum dispensing fee under the city’s plan, pharmacists can charge more than that for compound drugs or vacation supply. The report suggested city staff should clarify with the current benefits administrator the dollar limit on reimbursing dispensing fees for vacation supply.
Employee drug benefits cost the City of Toronto about $60 million each year, according to the report, which offered 25 recommendations to help improve oversight of the plan. “Our findings underscore the importance of a fiscally sound plan design and ongoing monitoring of unusual claim patterns by the city’s benefits administrator,” wrote Romeo-Beehler.
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Besides erectile dysfunction, the report also raised concerns about claims for opioids in 2016. Among the issues were claims for fentanyl patches. “In our 2016 analysis of claim data, we identified 31 claimants (27 active employees and four retirees) who were reimbursed potentially excessive quantities of fentanyl patches,” wrote Romeo-Beehler.