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Date: April 30, 2024 Tue
Time: 3:04 am
Time: 3:04 am
Results for medical fraud
2 results foundAuthor: U.S. Government Accountability Office Title: Medicaid: Additional Reporting May Help CMS Oversee Prescription-Drug Fraud Controls Summary: GAO found indicators of potential prescription-medication fraud and abuse among thousands of Medicaid beneficiaries and hundreds of prescribers during fiscal year 2011-the most-recent year for which reliable data were available in four selected states: Arizona, Florida, Michigan, and New Jersey. These states accounted for about 13 percent of all fiscal year 2011 Medicaid payments. Specifically, in these four states, GAO found the following: - More than 16,000 of the 5.4 million beneficiaries potentially engaged in "doctor shopping," by visiting five or more doctors to receive prescriptions for antipsychotics or respiratory medications valued at about $33 million. - About 700 beneficiaries received more than a 1-year supply of the same drug in 2011 at a cost to Medicaid of at least $1.6 million. This is an indicator of diversion, which is the redirection of prescription drugs for illegitimate purposes. As required by federal law, the Medicaid Drug Utilization Review program is a two-phase review process states use to promote safety while also monitoring prescription-drug activity for fraud. Federal law requires each state to report on the operation of its review program, a key monitoring tool that the Centers for Medicare & Medicaid Services (CMS) uses to oversee the review process in states, but GAO identified additional actions that could improve oversight. In the first phase, states use tools and eligibility screening to promote patient safety and avoid abuse before the drugs are dispensed. The second phase involves ongoing and periodic examination of claims data to identify patterns of fraud, abuse, gross overuse, or medically unnecessary care, and implement corrective action when needed. However, GAO identified two potential controls that are not included in CMS's current reporting requirements: - Lock-in programs for noncontrolled substances. Lock-in programs address doctor shopping by restricting beneficiaries who have abused the Medicaid program to one health-care provider, one pharmacy, or both, for receiving prescriptions. Lock-in programs have typically been used on controlled substances. Expanding lock-in programs that currently focus on controlled substances to restrict abusers of noncontrolled substances, such as the human immunodeficiency virus medications Atripla and Truvada, to a single prescriber or pharmacy may help address potential fraud and abuse. - Prohibition of automatic refills. Pharmacies permitting automatic refills automatically refill prescriptions for certain medications without any customer action. Concerns with pharmacy automatic refill include the potential for stockpiling, continued fill of discontinued medications, and increased cost and waste of prescription medications. Two states GAO reviewed-Florida and Arizona-have prohibited the practice. CMS does not collect information about lock-in programs for noncontrolled substances or automatic refill prohibitions, but doing so would help the agency determine whether additional guidance is needed. Details: Washington, DC: GAO, 2015. 64p. Source: Internet Resource: GAO-15-390: Accessed August 14, 2015 at: http://www.gao.gov/assets/680/671241.pdf Year: 2015 Country: United States URL: http://www.gao.gov/assets/680/671241.pdf Shelf Number: 136423 Keywords: Medicaid Fraud and AbuseMedical FraudPrescription Fraud |
Author: U.S. General Accounting Office Title: Health Care Fraud: Information on Most Common Schemes and the Likely Effect of Smart Cards Summary: What GAO Found GAO's review of 739 health care fraud cases that were resolved in 2010 showed the following: - About 68 percent of the cases included more than one scheme with 61 percent including two to four schemes and 7 percent including five or more schemes. - The most common health care fraud schemes were related to fraudulent billing, such as billing for services that were not provided (about 43 percent of cases) and billing for services that were not medically necessary (about 25 percent). - Other common schemes included falsifying records to support the fraud scheme (about 25 percent), paying kickbacks to participants in the scheme (about 21 percent), and fraudulently obtaining controlled substances or misbranding prescription drugs (about 21 percent). - Providers were complicit in 62 percent of the cases, and beneficiaries were complicit in 14 percent of the cases. GAO's analysis found that the use of smart cards could have affected about 22 percent (165 cases) of cases GAO reviewed in which the entire or part of the case could have been affected because they included schemes that involved the lack of verification of the beneficiary or provider at the point of care. However, in the majority of cases (78 percent), smart card use likely would not have affected the cases because either beneficiaries or providers were complicit in the schemes, or for other reasons. For example, the use of cards would not have affected cases in which the provider misrepresented the service (as in billing for services not medically necessary), or when the beneficiary and provider were not directly involved in the scheme (as in illegal marketing of prescription drugs). Details: Washington, DC: GAO, 2016. 46p. Source: Internet Resource: GAO-16-216: Accessed February 22, 2016 at: http://www.gao.gov/assets/680/674771.pdf Year: 2016 Country: United States URL: http://www.gao.gov/assets/680/674771.pdf Shelf Number: 137935 Keywords: Illegal MarketsMedical FraudPrescription Fraud |