Posts tagged 'medicaid fraud'
Many states do a poor job of regulating Medicaid fraud because it is a not a simple matter economically. After all, for ever dollar Medicaid brings into a state, there is a federal matching dollar hat the state receives. Some states even overpay Medicaid providers, collect matching federal funds, and collect kickbacks of overpayments, thus becoming part of the fraud problem.
The question then becomes, what is the sense behind turning the oversight of Medicaid over to the same government that is participating in the fraud? Their actions have created long waiting lists, rationing of care and poor delivery of not enough care, again controlled by the government.
There is another side to the issue, however. What happens when you need to make the numbers work? It’s important to look at the major problem. There are many honest and caring physicians who try to help as many individuals on Medicaid as possible. The problem is that even the busiest physicians that take Medicare can’t take more than about 28% of their caseload in Medicaid patients, they can’t afford to stay in business because the amount they are reimbursed is lower than the services provided. Therefore, if there are too many Medicaid patients seeing a particular doctor, he loses money until he can’t afford to stay in business any more.
We haven’t even talked about the number of children covered by Medicaid for various reasons. There are over 25 million kids that have various forms of Medicaid coverage. There are Targeted Case Workers and Case Management through Medicaid Rehabilitative Services who do all they can to deal with children’s’ physical and mental disabilities – getting help and services for them while keeping expenses to Medicaid and to physicians under control. A federal-state partnership that exists now to cover these expenses could be eliminated if some politicians get their way.
Looking at both sides, the hope is that the politicians will be able to work with the expenses while remembering that these issues are not only about finances, but at the heart of the issues are children and adults with vulnerabilities and disabilities that depend on the Medicaid system to help keep them well.
Walgreens Drug Stores agreed today to pay $35 million to the federal government for fraudulent activities regarding three prescription drugs. What was at the heart of the case was that Walgreen was switching out the prescribed drugs for more expensive brands and by switching these, they substantially increased the amount of money that Medicaid reimbursed them, thus substantially increasing their profits.
Medicaid recipients were unaware of this, and there has been no disclosure in the suit that any recipients were harmed, however, switching medication is not harmless. Just because it seems so far that nobody was hurt or killed in this situation, there are severe penalties for these practices because serious risks do exists. Plus, switching medications for profit is simply put, illegal.
Switching medications in this way is a violation of state and federal regulations that are designed to protect patients. In addition, pharmacies subject themselves to triple damages, civil penalties and attorneys’ fees. Usually, this, plus the willingness of insiders to report such fraudulent activities helps keep pharmacies in line with regulations, however, this case against Walgreens should be a warning that the government will pursue fraud aggressively.
For Medicaid recipients, it is important that you know that this what Walgreens did in this case is not the same as the pharmacy calling your doctor and asking if the medications could be switched. That is a practice that pharmacies use if they are trying to correctly fill a prescription with a substitute generic medication. In the Walgreens case, thousands of prescriptions were replaced without notifying anyone, and that is totally against regulations.
This case should let you know that if you receive Medicaid benefits, there are agencies looking out for your welfare and trying to protect you, and reassure you that most pharmacies try to help their clients by filling the right prescriptions and doing the right thing.
It may seem like New York doesn’t have many scams (just kidding), but one scam that is very real and is being addressed by New York’s Attorney General Andrew Cuomo is home health care fraud that is paid for with Medicaid dollars.
Cuomo has started “Operation Home Alone” which is a new program that is rooting out con artists that pose as home health care workers, but really are not. These scams have cost the taxpayers of New York millions of dollars.
The way it works is that a real home health care worker has to have 75 hours of training and be certified to work at home with individuals who need certain health services. The certification is very important because it means that an individual has been trained to treat wounds, feed, bathe and dress individuals and several other health procedures.
These uncertified home health care imposters are not only dishonest, and not only basically stealing millions of Medicaid dollars, but they are also dangerous. Since they are not trained, it is extremely risky for them to be helping individuals at risk with medical and other health issues. For instance, the average person does not know first aid or CPR. They do not know the correct way to lift someone to help them from a wheelchair to a bed, or vice-versa. They do not know how to take or read blood pressure or blood sugar or what to do in case of a seizure. And that’s the easy stuff!
Most individuals that need home health care receive it because they have health issues that they need help with. A home health care worker is taught how to keep track of and monitor all day-to-day symptoms, vital signs and issues that come up. They know how to track and record information that shows how a person’s health is progressing – for better or for worse. An untrained and un-certified individual usually knows few, if any, of these procedures.
So far, Andrew Cuomo has caught quite a few of these companies who are nothing more than rings of uncertified workers fleecing the system out of a lot of money and putting patients at risk. Cuomo has filed criminal and civil charges to the extent of the law and he is not backing down.
If you are a New Yorker, you can be happy and proud that your Attorney General is trying to protect your citizens – especially those most vulnerable – and protect the taxpayers’ money. If you feel that you have been the victim of this type of fraud by an uncertified healthcare worker, contact Medicaid at www.medicaid.gov or call Cuomo’s office, which is listed under State of New York, Attorney General.
