#AceHealthNews says the “Centers for Medicare & Medicaid Services (CMS) has published a final rule that offers states new flexibilities in providing necessary and appropriate services to elderly and disabled populations on a more individualized basis. Authorized through section 2402 of the Affordable Care Act, the regulation outlines the optional state plan benefit to furnish home and community-based state plan services and draw federal matching funds. As a result, states will be able to design and tailor Medicaid services to better accommodate individual needs. The final rule includes other changes to the HCBS waiver provisions to convey expectations regarding person-centered plans of care, to provide characteristics of settings that are home and community-based as well as settings that may not be home and community-based, to clarify the timing of amendments and public input requirements when states propose modifications to HCBS waiver programs and service rates, and describes strategies state Medicaid systems can pursue to make sure that ageing citizens and individuals with disabilities are supported in the most integrated setting possible.
#AceHealthNews says when you are elderly and infirm ,would you expect your doctor, drug company and advisers, to give you a “Medicare Drug Plan” you do not really need. Well according to this recent article that is exactly what happened to this person, under this “Medicare Drug Fraud” read the story ……………………………………………. below: comment and share
Story of the Events:
At another time in her life, Denise Heap might have tossed aside the insurance forms listing the drugs prescribed to her mother.
The “explanation of benefits” forms came like clockwork and didn’t require any action on her part.
But Heap was worried about her mother, Joyce, who was in the end stages of Alzheimer’s disease. Her health had inexplicably declined in the Los Angeles-area nursing home where she’d been living. So in April, when a thick envelope arrived from her mother’s Medicare drug plan, Heap scrutinized it.
What she found was frightening: Her 77-year-old mother was receiving a raft of medications Heap had never seen before.
As Heap began Googling the drugs, she realized something was drastically wrong. Either her mother was being given expensive medications for conditions she didn’t have 2014 such as breast cancer, asthma, emphysema and high cholesterol 2014 or something sinister was going on: Someone was using her mother to steal drugs.
“I flipped,” Heap said. Medicare’s prescription program, known as Part D, paid for more than “$10,000 worth of meds” in just three months, she said.
She first called Medicare to report her suspicions, she said, then the insurance company that managed her mother’s Medicare drug plan. Neither, she said, seemed very concerned.
“I was like, No, No, No, You have to understand. I am trying to help you guys,'” she said.
Soon, Heap became convinced someone had stolen her mother’s identity while she was living at a nursing home run by an Armenian couple. The couple kept moving the location of the nursing home. And Heap believed they had over-sedated her mother with high doses of antipsychotics, inappropriately treating her blood pressure and allowing bed bugs to feast on her.
“I knew something crooked was going on,” said Heap, 59, who, with her mother, had co-founded a Holocaust education nonprofit in the 1990s to document stories of German resistance to Hitler.
Frustrated, Heap called Los Angeles County sheriff‘s Sgt. Steve Opferman, head of a task force specializing in prescription drug fraud. As soon as Heap began describing what had happened, Opferman said he knew her mother had been caught up in a fraud scheme involving Armenian organized crime.
Opferman and other investigators say criminals wager that patients and their families will not be like Heap. They bank on the fact that their victims 2014 Medicare beneficiaries 2014 will be too old or too sick to review insurance forms summarizing the medications and services billed in their names. And they count on the tendency of busy family members to give such forms a cursory glance, if that.
“Suffice it to say most people don’t pay attention, let alone know what they’re looking at,” Opferman said.
But Heap’s case, and others like it, shows the important role patients and their families can play in uncovering fraud within Part D. The program now covers 36 million seniors and disabled people and fills 1 in 4 prescriptions nationwide. Last year, it cost taxpayers $62 billion.
In an earlier report, ProPublica found that Medicare’s system for pursuing such fraud is so cumbersome and poorly run that schemes can quickly siphon away millions. Tips such as Heap’s can come into private insurers, which run Part D for Medicare, to contractors hired by Medicare to spot fraud, or to the U.S. Department of Health Human Services inspector general, which investigates health care fraud. But only a small percentage of cases funneled through this chain are prosecuted.
Reporters, using Medicare’s own data, were able to identify scores of doctors whose prescribing within the program followed known patterns of fraud: the cost of doctors’ prescribing jumped dramatically 2014 sometimes by millions of dollars 2014 from one year to the next and they chose brand-name drugs that scammers’ can easily resell.
Some doctors claimed that they 2014 like some of the patients involved 2014 were unwitting victims of identity theft. In other cases, federal investigators found, the doctors were paid for writing bogus or inappropriate prescriptions.
In a response to these findings, a Medicare official said more focus has been placed on fraud detection within Part D.
The drugs listed on Joyce Heap’s explanation of benefits forms are those most-desired in such fraud schemes. They included the asthma drugs Spiriva and Advair Diskus, for which her insurance plan paid nearly $270 a month each, the cholesterol drug Crestor, which cost nearly $170, and the antipsychotic Abilify, for which the plan paid about $920 for a 30-day supply.
Opferman said Heap’s call launched an investigation that uncovered a large Part D scheme allegedly connecting the owners of the nursing home to a North Hollywood pharmacy operation, including evidence that other residents’ identities were used. A September search of the pharmacy where Heap’s mother’s prescriptions were filled found evidence that drugs were being relabeled or repackaged for resale, he said.
The doctor who prescribed the drugs has denied prescribing the majority of them, Opferman said. The case is now part of an ongoing investigation by California’s Department of Justice and his group, he said.
Opferman said investigators might never have known of the scheme without Heap’s tip.
Joyce Heap didn’t live long after her daughter unearthed the problems.
She improved briefly after moving to a new nursing home, where a doctor reduced her psychiatric medications, Denise Heap said. But she died of a heart attack on April 21.
In the months following her mother’s death, Heap said, she sent letters alerting Medicare and her mother’s insurer to the possible fraud. In July she wrote, “Please note that 100% of the prescriptions charged in April 2013 2026 are FRAUDULENT.”
Heap said she is “outraged” Medicare didn’t follow-up and ask detailed questions about her allegations. In fact, it was either her insurer or Medicare 2014 she can’t recall which 2014 that recommended she call the local sheriff if she was worried.
“I would have thought immediately they would have gotten on it,” she said.
But Heap said she is mostly tormented that she didn’t know such fraud schemes existed 2014 and that elderly people like her mother could become prey.
“It’s a hard thing to live with,” she said, tearfully. “I feel like I failed.”
Courtesy of: Tracy Weber and Charles Ornstein ProPublica, Dec. 31, 2013, 10:20 a.m.
- “Let the Crime Spree Begin”: How Fraudsters Benefit from Medicare’s Drug Plan(alternet.org)
- Medicare Looks To Narrow Discrepancy On What It Spends In Different Parts Of U.S.(kaiserhealthnews.org)
- Real Solutions to Preventing Prescription Drug Abuse, Diversion at the Pharmacy Counter| Commentary(rollcall.com)
- How Fraud Flourishes Unchecked In Medicare’s Drug Plan(npr.org)
- Caught up in a Medicare drug fraud(armonews.wordpress.com)