Medicaid Drug Fraud: Federal Leadership Needed to Reduce Program Vulnerabilities : Report to Congressional Requesters |
From inside the book
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Page 2
... 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 ...
... 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 ...
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... professional licenses for physicians and pharmacists . The severity of the penalty , however , may work against prosecutors seeking convictions . In all four of the Florida cases we examined in which medical professionals were charged ...
... professional licenses for physicians and pharmacists . The severity of the penalty , however , may work against prosecutors seeking convictions . In all four of the Florida cases we examined in which medical professionals were charged ...
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... Professional Medical Conduct Office of Professional Discipline Board of Regents Bureau of Medicaid Fraud and Abuse • Investigates providers for removal from Medicaid ; refers them for criminal prosecution ; refers for professional ...
... Professional Medical Conduct Office of Professional Discipline Board of Regents Bureau of Medicaid Fraud and Abuse • Investigates providers for removal from Medicaid ; refers them for criminal prosecution ; refers for professional ...
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... professional licensing authorities , which have the power to suspend or revoke a provider's license to practice . In a similar vein , the HHS Inspector General recently agreed to exclude New York state providers convicted of Medicaid ...
... professional licensing authorities , which have the power to suspend or revoke a provider's license to practice . In a similar vein , the HHS Inspector General recently agreed to exclude New York state providers convicted of Medicaid ...
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... professional solely for his or her own use ) but did not review their complete case files in search of others . Thus , it is likely that we achieved neither a complete set of related cases nor strict comparability among the states ...
... professional solely for his or her own use ) but did not review their complete case files in search of others . Thus , it is likely that we achieved neither a complete set of related cases nor strict comparability among the states ...
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...