We’ve all heard the many stories of how Medicaid and Medicare are guilty of wasteful spending. The government’s own General Accountability Office (GAO) has long since designated Medicaid as a “high-risk” program. It says it’s “particularly vulnerable to fraud, waste, abuse and improper payments”. Even the Department of Health and Human Services, or HHS, reports an improper payment rate of nearly 10 percent. If you’re wondering what that equates to across the nation, it adds up to a cool $40 billion in Medicaid spending deemed either wasteful and/or fraudulent. And now, Medicare is in the spotlight as paying for drugs for the deceased is becoming a problem.
In a new report from the same HHS says that a particular Medicare rule allows for payments to be made for prescriptions filled up to 32 days after a patient has died. The report says that obviously, drugs for the deceased don’t meet the Medicare coverage requirement and that changes should be made immediately. Medicare, for its part, has already said it’s working on a new formula that would catch those errors before they’re made.
Medicare is a big program; mistakes are bound to happen, but it’s the way that they’re happening, the inconsistency in how they’re happening and the fact that “no one knows anything”. Medicare covers around 55 million seniors and disabled people. It’s only been since 2006 that prescription coverage has been delivered through private insurance plans. This was one of the larger Medicare expansions, and it’s also been one of the biggest areas where fraud and scams occur.
How it was Discovered
The investigators took a “tiny sliver” of claims for just one prescription drug in 2012 and examined them. They cross referenced them with death records and found that program paid for drugs for 158 beneficiaries after they had died. Just that small number equated to a taxpayer bill of $292,381, an average of $1,850 for each beneficiary. For whatever reasons, Medicare’s program allows these overpayments to happen. Even more disturbing is that half of those prescriptions they examined were actually filled by someone living. Often, multiple prescriptions were filled.
A Few of the Findings
In one instance, Medicare paid $1,200 for an HIV prescription for a 90-year-old Boston-area beneficiary that was dispensed 25 days after he died. The man had no history of HIV in his Medicare record.
In another instance, a Miami pharmacy filled a prescription for an 80-year-old beneficiary 16 days after he died. Medicare paid $1,800. Later the same day, the same pharmacy then dispensed the same two drugs on behalf on an 81-year-old woman who died 10 days earlier.
Of course, no one knows what happened to the drugs after they were given to the “patient”. Some say because they were HIV drugs in many instances, they could have been delivered “underground” to help those with HIV but who could not afford the medications. The newer HIV drugs are extraordinarily high and out of reach for many patients.
Prescription drug fraud is rampant in this country, but it shouldn’t affect the millions who rely on Medicaid and Medicare. To learn more about seeking coverage for yourself or your loved one, contact our team of estate planning lawyers today.