The Majority of Providers Reviewed Used Medicare Part D Eligibility Verification Transactions for Potentially Inappropriate Purposes

The Centers for Medicare and Medicaid Services (CMS) requested that OIG audit a mail-order pharmacy's Medicare Part D Eligibility Verification Transactions (E1 transactions). To address CMS's request, we conducted this audit of E1 transactions, which included the requested provider's transactions. During our audit, we discovered that providers were taking advantage of gaps in CMS's program integrity in E1 transactions. Because E1 transactions contain beneficiary protected health information (PHI), we wanted to verify that the providers were appropriately using E1 transactions for their intended purposes.