A recent report from a federal watchdog has found that certain loopholes in current Medicare regulations make the government particularly susceptible to fraud. A review by the inspector general of the U. S. Department of Health and Human Services found that Medicare patients with HIV were often overprescribed or given medications they simply didn't need.
The IG's report, issued in early August, estimates that Medicare's prescription drug program known as part D was bilked to the tune of more than $30 million in 2012 through a wide range of fraudulent schemes.
One of the most egregious cases cited happened right here in Miami when a 48-year-old man reportedly traveled to over 28 different pharmacies to collect drugs used to treat HIV. Officials estimate the value of those drugs at over $200,000 and nearly 10 times more than what average patients should receive over the course of the year. Investigators may have been tipped off by the unusually high numbers of prescriptions given to the patient, allegedly written by 16 different health providers.
Another case involved a 77-year-old woman in Detroit who received medication despite never having been diagnosed with HIV, nor having visited the doctors who provided the prescriptions. The IG's investigation claims the elderly woman filled prescriptions for $33,500 worth of HIV medications.
The report highlights one of the central problems of the Part D program is that its efforts to quickly get medication to patients with HIV may have left it vulnerable to fraud. Currently, the program's rules place people receiving HIV drugs under a protected class. This means that insurance companies must cover the cost of these medications without exception and are not able to require prior approval if the insurers are being paid through Medicare.
The Centers for Medicaid and Medicare Services says that they want Congress to review the report findings and tighten regulations.
Sometimes, individuals who are facing allegations of federal crimes like Medicaid or Medicare fraud may be called before a grand jury to determine whether they should be tried for the crimes that they are accused of committing. Generally, it is a wise decision to have legal representation throughout this process. The federal court system can be difficult to understand, and it is necessary to preserve your rights and other legal interests.
Source: Pacific-Standard, "Why Is Medicare Spending So Much Money on Suspicious HIV Prescriptions?" Charles Orenstein, Aug. 12, 2014