Medicaid Drug Fraud: Federal Leadership Needed to Reduce Program Vulnerabilities : Report to Congressional Requesters |
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... overpayment amounts to be recovered . Agencies need to consider the universe of a provider's claims to establish an ... overpayments once had priority in bankruptcy cases , but it was eliminated by the Bankruptcy Reform Act of 1978 ...
... overpayment amounts to be recovered . Agencies need to consider the universe of a provider's claims to establish an ... overpayments once had priority in bankruptcy cases , but it was eliminated by the Bankruptcy Reform Act of 1978 ...
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... overpayments sought . Medicaid agency officials attribute their reluctance to resource limitations , exacerbated by the age of the cases at closure . Moreover , federal requirements tend to discourage states from pursuing comprehensive ...
... overpayments sought . Medicaid agency officials attribute their reluctance to resource limitations , exacerbated by the age of the cases at closure . Moreover , federal requirements tend to discourage states from pursuing comprehensive ...
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... overpayments under this provision 24 New York has used this authority against various providers , including pharmacies , and been upheld in court . Texas has a similar termination provision , but has never used it . HCFA prepared a ...
... overpayments under this provision 24 New York has used this authority against various providers , including pharmacies , and been upheld in court . Texas has a similar termination provision , but has never used it . HCFA prepared a ...
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... overpayments , fines , and other financial penalties , states have developed several recovery initiatives . New York requires high - volume Medicaid pharmacies to post performance bonds or other financial security to improve the state's ...
... overpayments , fines , and other financial penalties , states have developed several recovery initiatives . New York requires high - volume Medicaid pharmacies to post performance bonds or other financial security to improve the state's ...
Common terms and phrases
action administrative appendix assets BCCI bill Medicaid charges Civil Monetary Penalties CMPL controlled substances Controlled Substances Act defraud Department of Justice Department of Social detection Divert Drugs Drug diversion schemes Drug Enforcement Administration Economic Incentives enrollment example excluded from Medicaid Extent and Persistence False Claims Act felony Florida Four States Visited HCFA health care fraud high-volume providers identify illegal individuals Initiatives Focusing Initiatives in Four involved licensing Medicaid agency Medicaid billings Medicaid drug diversion Medicaid Prescription Drug Medicaid program Medicaid recipients Medicare MFCU officials middlemen million networks noncontrolled obtained operations overpayment amount owners ownership participants patients Penalties Law percent Persistence of Medicaid pharmacies pharmacist Pharmacy price pill mill Post and clear prescribing physician Prescription Drug Diversion prescription forms professional sanctions pursued recover losses Regional Offices requirements restitution amounts Schedule Schedule II scrips suspect labs targeting task forces Texas U.S. Attorneys Up-Front Controls verification system w/codeine York Zantac
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...