Medicaid Drug Fraud: Federal Leadership Needed to Reduce Program Vulnerabilities : Report to Congressional Requesters

Front Cover

From inside the book

What people are saying - Write a review

We haven't found any reviews in the usual places.

Selected pages

Common terms and phrases

Popular passages

Page 14 - Medicaid for dispensing large volumes of prescription drugs. For 3 years the volume of prescriptions was improbably high- -in many cases more than 20 prescriptions a day for a single recipient. The state's reporting system, however, did not trigger an investigation of the pharmacist nor of any of the recipients. A tip...
Page 8 - One key element of such a strategy might be the designation of a unit within HCFA responsible for (1) conducting continuing evaluations of state initiatives targeting prescription drug diversion and other Medicaid fraud and (2) providing guidance and technical assistance tailored to individual state problems.
Page 35 - Under the act controlled substances (narcotics and dangerous drugs) have been divided into five schedules on the basis of their potential for abuse, accepted medical use, and accepted safety under medical supervision. Substances included in schedule I are those with a high potential for abuse, no accepted medical use, and a lack of accepted safety. Those in schedules II through V decrease in potential for abuse and increase in accepted medical use. The placement of a drug in any one of these schedules...
Page 18 - One pharmacist-owner sold his store but is still employed there as a pharmacist, and the other two re-enrolled in Medicaid under new ownership. One of the new owners is married to the convicted former owner.
Page 3 - For example, some pharmacists routinely added medications to customers' orders, keeping the extras for themselves or to sell to others. Clinics inappropriately provided Medicaid recipients with completed prescription forms (scrips) that were then traded for merchandise from local pharmacies or sold on the street to the highest bidder. Some pills costing 50 cents at the pharmacy were resold for as much as $85. A common scheme is the so-called 'pill mill...
Page 4 - Zantac;4 and an organized network of colluding physicians, pharmacists, patient brokers, and other middlemen, some of whom transferred money overseas through the Bank of Credit and Commerce International (BCCI).
Page 12 - ... -about 10 percent of the state's total Medicaid expenditures for prescription drugs. The Federal Bureau of Investigation (FBI) has testified before the Congress on the continued existence in 1992 of such fraud in New York and other states. WHY DIVERSION PERSISTS Several factors complicate attempts to curb these schemes. Some relate to data inadequacies: Medicaid agencies typically do not have data available that are accurate, complete, timely, and in convenient form to highlight aberrant billing...
Page 2 - ... program for a period of time, and professional licensing agencies may suspend or revoke their licenses to practice in that state. Alternatively, they may receive lesser penalties--or none at all. Federal action may also be taken: the HHS Office of the Inspector General may--and in some cases must--direct HCFA to exclude the provider from participation in Medicare and other federal health programs. Also, the Department of Justice may seek substantial monetary penalties under the False Claims Act,...
Page 3 - Several factors complicate attempts to curb these schemes. Some relate to data inadequacies. Medicaid agencies typically do not have data available that are accurate, timely, and complete and in convenient form to highlight aberrant billing or referral patterns.
Page 7 - ... pursued. In Florida, for example, the MFCU rejects more than 90 percent of the state Medicaid agency's referrals because of its own staffing constraints. This leads to a no-win situation: Medicaid agency personnel are reluctant to invest a lot of effort developing cases that are likely to be rejected, and MFCU officials are more likely to reject ill-prepared cases because of the additional burden imposed on their own limited staff. In each state we visited, officials expressed frustration at...

Bibliographic information