A garden variety Medicaid fraud case with a twist. A pharmacist in the Pittsburgh area was arrested for false claims to Medicaid and a private insurer for medications not ordered or provided. However, the pharmacist is also accused of submitting false rebate requests for drugs such as Levitra, for erectile dysfunction, and Marinol, a synthetic marijuana. The twist is that the drug rebate requests are also believed to be false because they relate to claims for services provided to prisoners in a county jail.
Click here to read the complete story.
Monthly Archives: April 2009
Medicaid Fraud Enforcement Doubles In NY
Attorney General Andrew Cuomo announced that the State of New York has recovered $263 million in Medicaid funds in 2008, the most in any year and up from $114 million in 2007. $35 million came from one managed care provider, Healthfirst, and $28 million from civil settlements with home health care companies. There were also 150 convictions for Medicaid fraud in the State of NY last year, 35 related to fraudulent home health care claims.
To read the press release click here.
Florida Passes Tougher Anti-Medicaid Fraud Law
In a move targeted to increase health care fraud enforcement by the State of Florida, the Florida legislature has recently passed legislation containing a number of new fraud provisions, including:
* elevating Medicaid fraud from a third degree felony to first, second and third degree felonies based upon dollar amounts of fraud and increasing fines to five times the amount of the fraud;
* designating Miami-Dade County as a “health care fraud crisis area” and increasing the monitoring of home health care in Miami-Dade County requirements that owners of home health agencies to be residents of the United States for at least five years or to post a $500,000.00 bond to own a health care clinic, a home health agency or a DME company;
* increasing the number of disqualifying prior criminal offenses for home health care business ownership;
* an increase in funding for rewards for people who report health care fraud and awarding 25% or $500,000 as a reward for successful actions based upon information received;
* limits a defendant’s ability to collect attorney’s fees if successful in defending a false claims action;
* prohibits alteration of records after the commencement of an investigation or audit; and
* provides that Medicaid program terminated provider’s names will be placed on a website and physician practitioner profiles will indicate if a practitioner was terminated from the Medicaid Program.
To read the new law, click here.
What is Medical Necessity?
The term “medically necessary” in the context of Medicare and Medicaid reimbursement has been under some scrutiny lately. Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medicaid has a similar definition. For items or services where there is no specific limitation based upon a coverage policy, medical necessity has often been left to the good faith determination of a physician. However, in several prosecutions of physicians for infusion of HIV drugs, the government has relied on fraudulent diagnosis or unnecessary prescribing of medications as a basis of prosecution, citing to the physician motive of profit over appropriate patient care. In addition, the 11th Circuit Court of Appeals in Atlanta has recently held that the Medicaid program in Georgia can overrule a physician’s determination of medical necessity.
The case involved a young girl whose physician ordered additional nursing care than was available under a Medicaid policy. A Federal District Court Judge found that the state could not override the physician’s order and that “the state’s discretion is limited to a review of the request for fraud, abuse of the Medicaid system, and whether the service is within the reasonable standards of medical care.” The Eleventh Circuit disagreed, saying both the state and the treating physician have roles in determining what is medically necessary. It cited a federal regulation that says a Medicaid agency “may place appropriate limits on a service based on such criteria as medical necessity or utilization control procedures.” The Court concluded that “A private physician’s word on medical necessity is not dispositive.”
The case is Moore v. Medows, No. 08-13926. To read the case, click here. To read more, click here.
Florida Legislators Move to Prevent Doctor Shopping
Legislation before the Florida House and Senate would require a controlled substances reporting database containing all prescribing and dispensing information related to certain controlled substances.
The purpose and intent of the statute is to prevent drug abuse and profit making by the over prescribing of controlled substances. The database would be accessible by pharmacists and practitioners dispensing medications to patients to make sure a patient has not received multiple prescriptions for controlled substances. However, somewhat disconcerting from a civil liberties perspective is that the database would also be accessible to law enforcement as part of an “active investigation.” This includes State Boards, Medicaid fraud investigations or any investigation concerning fraud, prescribing, or dispensing controlled substances which seems to include any time law enforcement wants the information. Active investigation is defined as “an investigation that is being conducted with a reasonable, good faith belief that it could lead to the filing of administrative, civil, or criminal proceedings, or that is ongoing and continuing and for which there is a reasonable, good faith anticipation of securing an arrest or prosecution in the foreseeable future.”
Th read the legislation click here and here.