Medicaid Drug Fraud: Federal Leadership Needed to Reduce Program Vulnerabilities : Report to Congressional Requesters |
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Page 8
... performed our field work in accordance with generally accepted government auditing standards between December 1991 and December 1992. As you requested , we did not obtain written agency comments on this report because of time ...
... performed our field work in accordance with generally accepted government auditing standards between December 1991 and December 1992. As you requested , we did not obtain written agency comments on this report because of time ...
Page 13
... performed or medications not provided . In Florida , Medicaid recipients traded scrips to pharmacies for cash or ... perform numerous unneeded tests for which they bill Medicaid . Pharmacists fill the scrips and bill Medicaid . Medicaid ...
... performed or medications not provided . In Florida , Medicaid recipients traded scrips to pharmacies for cash or ... perform numerous unneeded tests for which they bill Medicaid . Pharmacists fill the scrips and bill Medicaid . Medicaid ...
Page 23
... Perform tests , Draw blood , write scrip , bill Medicaid Recipients go to- Laboratories bill Medicaid Middlemen Paid " commission " from labs Funds Funds Scrip Possible common ownership Pharmacies Fill scrip , bill Medicaid Recipients ...
... Perform tests , Draw blood , write scrip , bill Medicaid Recipients go to- Laboratories bill Medicaid Middlemen Paid " commission " from labs Funds Funds Scrip Possible common ownership Pharmacies Fill scrip , bill Medicaid Recipients ...
Page 31
... services , the person under whose supervision they were furnished , and the person causing them to be furnished . Page 31 GAO / HRD - 93-118 Medicaid Drug Fraud Appendix II Objectives , Scope , and Methodology We performed.
... services , the person under whose supervision they were furnished , and the person causing them to be furnished . Page 31 GAO / HRD - 93-118 Medicaid Drug Fraud Appendix II Objectives , Scope , and Methodology We performed.
Page 32
... performed this study at the request of Congressman Rangel in his former capacity as the Chairman of the House Select Committee on Narcotics Abuse and Control ; and of Congressman Towns , Chairman , Subcommittee on Human Resources and ...
... performed this study at the request of Congressman Rangel in his former capacity as the Chairman of the House Select Committee on Narcotics Abuse and Control ; and of Congressman Towns , Chairman , Subcommittee on Human Resources and ...
Common terms and phrases
actions administrative Appendix I Extent assets audit providers BCCI charges Civil Monetary Penalties CMPL Controlled Substances court defraud Department of Justice Department of Social detection Divert Drugs Drug diversion schemes Drug Enforcement Administration Drug Fraud Extent enrollment example excluded from Medicaid Extent and Persistence extent of Medicaid False Claims Act federal agencies federal health Florida focused GAO/HRD-93-118 Medicaid Drug HCFA health care fraud high-volume providers identify illegal individuals initiatives Investigates and prosecutes lab tests law enforcement agencies licensing Medicaid agency Medicaid billings Medicaid drug diversion Medicaid Drug Fraud Medicaid Prescription Drug Medicaid program Medicaid providers Medicare MFCU officials middlemen million networks numbers obtained offenders overpayment amount owners ownership participants patients Penalties Law percent Persistence of Medicaid pharmacies pharmacist Post and clear prescribing physician Prescription Drug Diversion prescription forms professional sanctions program losses recover losses Regional Offices requirements restitution Schedule II scrips state's task forces Texas U.S. Attorneys York
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...