2 Objectives Define the terms Fraud, Waste & Abuse Discuss New Jersey Medicaid Fraud Division’s Work PlanIdentify key components of the Patient Protection and Affordable Care Act (PPACA)List the key components of Compliance ProgramsDescribe the changes in Medicare and Z-PIC AuditsDiscuss Case Studies
3 Definition of Fraud"Fraud" means an intentional deception or misrepresentation made by any person with the knowledge that the deception could result in some unauthorized benefit to that person or another person, including any act that constitutes fraud under applicable federal or State law.N.J.S.A. § 30:4D-55
4 Definition of WasteWaste, typically not a criminal or intentional act, can be described as the over-utilization or misuse of services
5 Definition of Abuse"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices and result in unnecessary costs to Medicaid or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. The term also includes recipient practices that result in unnecessary costs to Medicaid.N.J.S.A. § 30:4D-55
6 New Jersey Medicaid Fraud Division The New Jersey "Medicaid Program Integrity and Protection Act" established the Office of the Medicaid Inspector GeneralOn June 29, 2010 the Office of the Medicaid Inspector General was placed under the Office of the State Comptroller.OMIG renamed Medicaid Fraud Division (MFD)
7 New Jersey Medicaid Program Integrity and Protection Act The State of New Jersey expends more than $ 9 billion in taxpayer funds to fund the Medicaid program each year;Centralizes fraud recovery efforts and establishing an independent Office of the Medicaid Inspector General by statute to prevent, detect, and investigate fraud and abuse and coordinate the anti-fraud efforts of all State agencies funded by MedicaidFor each fiscal year beginning after the fiscal year in which this act takes effect, the Governor shall recommend and the Legislature shall appropriate at least $ 3,000,000 from the General Fund to the Office of the Medicaid Inspector General to effectuate the purposes of this act.
8 Medicaid Fraud Division – Mission The DivisionInvestigates fraud, waste and abuse;Recovers Medicaid funds via audits;Enforces Medicaid rules and regulations;Reviews the quality of care given to Medicaid recipients;Performs background checks on all Medicaid provider applicantsExcludes or terminates providers from the Medicaid program;Refers criminal prosecutions to the Attorney General's office
9 New Jersey Medicaid Program Integrity and Protection Act - Powers To conduct and supervise all State government activities, except those of the Medicaid Fraud Control Unit in the Department of Law and Public Safety, relating to Medicaid integrity, fraud, and abuse;To call upon any department, office, division, or agency of State government to provide such information, re-sources, or other assistance as the Medicaid Inspector General deems necessary to discharge the duties and functionsTo direct all public or private Medicaid service providers or recipients to cooperate with the office and provide such information or assistance as shall be reasonably required by the office.
10 New Jersey Medicaid Program Integrity and Protection Act - Powers To establish, in consultation with the department and the Attorney General, guidelines under which the withholding of payments or exclusion from Medicaid may be imposed on a provider or shall automatically be imposed on a provider;To review the utilization of Medicaid services to ensure that Medicaid funds, regardless of which agency administers the service, are appropriately spent to improve the health of Medicaid recipients;To review and audit contracts, cost reports, claims, bills, and all other expenditures of Medicaid funds to determine compliance with applicable laws, regulations, guidelines, and standards, and enhance program integrity;To consult with the department to optimize the Medicaid management information system in furtherance of the mission of the office. The department shall consult with the Medicaid Inspector General on matters that concern the operation, upgrade and implementation of the Medicaid management information system;To coordinate the implementation of information technology relating to Medicaid integrity, fraud, and abuse; andTo conduct educational programs for Medicaid providers, vendors, contractors, and recipients designed to limit Medicaid fraud and abuse.10
11 MFD – What to ExpectIncreased Coordination with Managed Care Organizations (“MCO”)DMAHS currently contracts with four MCOs Monthly Meetings; Data Sharing; Data Mining2011 MCO TargetsIdentify Recipients with Multiple Identification NumbersOver-payments for Newborns
12 MFD – What to Expect Changes to the Audit Process MFD will review pharmacy and DME audits that will be performed by Molina Medicaid and other contractorsSelection Criteria for AuditsMedicaid dollars billed on a yearly basisProvider typeSignificant changes to Medicaid billings on a year to year basisComplaints from the publicProviders subject to corrective Action PlansLength of time since last audit/ investigationServices billed
13 MFD – What to Expect Onsite Audits A letter will be sent to the provider (scope, length, and authority for audit)Entrance conference - meeting with each individual providerExit Conference – to discuss preliminary findingsIssuance of a Draft Audit Report15 days to respond with objections and supporting documentsIf no response then report becomes final
14 MFD – What to Expect Audit Techniques Statistical Probability Sampling Simple Random Sampling – Random SelectionSystematic Sampling – (i.e. claims 5, 10, 15, )Stratified Sampling (grouping similar claims)Cluster Sampling (grouping of less similar claims)Non- Statistical Probability Sampling (by time, auditor’s judgment, etc.)Data Mining – Will become the primary internal referral source for both the Audit team and Investigations Unit
15 MFD – What to Expect Recovery and Exclusion Recovery Protocol Withholding of paymentsPayment arrangementsCertificate of DebtExclusionRecovery ProtocolOnce a final audit report is submitted, a Notice of Claim will be issuedProvider then has 20 days to request a pre-hearing conference to settle the matterIf no agreement, then a Notice of Demand will be issued and the Provider has 20 days to request a hearing with the OAL
16 Review of ExclusionsExcluded providers may not treat, order, or bill for services rendered to Medicaid recipients.May last from 3 – 8 years, or moreIf excluded provider is involved in the treatment, MFD will seek to recoup payment and may also seek damages and false claims penalties from the employer
17 Exclusion ListsAccording to § , plan sponsors “should review the HHS OIG and GSA1 exclusion lists at least once a year, and have processes in place to prevent the payment of claims for services provided by excluded providers.”List of Excluded Individuals and Entities (LEIE)Maintained by OIGExcluded Party List System (EPLS)Maintained by GSA1 GSA: General Services Administration
18 Exclusion ListsSponsors should require that all new and existing employees disclose any “debarment, exclusion, or other event that makes them ineligible to perform work related directly or indirectly to Federal health care programs”1Sponsors must implement a policy to check exclusion lists before hiringSponsors should obtain certifications from pharmacies that they will review the exclusion lists upon hiring and annually thereafter and if an employee is found on such lists, he/she will be immediately removed from any work related directly or indirectly to all Federal health care programs and the pharmacy will take appropriate corrective actions1 See §
19 Medicare Exclusion List Verification (Pharmacy Personnel) Pharmacy Personnel NameVerification DateDate of TerminationEXAMPLE
20 What This Means for Pharmacies PIC and owner should check all its employees online at least once a year but monthly would be betterPIC and owner should have each new employee sign a document indicating he/she has not been and is not debarred. This should be recertified each year
21 Exclusion Lists Employment Restrictions Includes Medicare, Medicaid, & other State Programs (PAAD, Senior Gold, etc.)Not limited to services directly provided by Excluded practitionerNo automatic reinstatement; must reapplyStrict time limit for appeal process
22 MFD – What to Expect MFD Investigations Common practices investigated Staff of 20 investigatorsIncludes law enforcement and healthcare professionalsCommon practices investigatedBilling for services not renderedProviding medically unnecessary servicesSubmitting duplicate claimsUpcodingBuying back and re-dispensing medicationDrug DiversionWill include interviews and analysis of claims data
23 MFD – What to Expect MFD will also review: The relationship between the ordering physician and the pharmacyWhether the physician is licensed at the time of prescribingSystem EditsOrganizations that use the services of excluded providersProviders with higher Medicaid claims than comparable pharmaciesWhether there is evidence of a existing physician-patient relationship
24 Examples of Edits Controls on early refills Limits on the number of days before a refill is permittedEdits to prevent payment for statutorily excluded drugsLimits on the number of times a prescription can be refilledBrand name versus genericExcessive claims for controlled substancesStep therapy edits
25 Examples of Edits (con’t) Number of prior authorizationsReal time contraindication (e.g. drug-drug interactions)Sex and age edits compared to the drug prescribedTherapeutic editsInsufficient or excessive dosage editsIdentifying drugs provided outside of the Part D benefit by Patient Assistance Programs
26 What This Means for Pharmacies Follow-up with patients who repeatedly bring prescriptions in to fill too earlyDo spot checks to confirm generic substitution is being carried out as per state lawDo spot checks on CDS usage by patients to detected abuse patterns. Consider CDS class, addictive properties, street value, and geographic abuse patterns
27 MFD – What to ExpectThe new mantra: “Becoming a Medicaid provider is a privilege, not a right”Increased scrutiny of Provider ApplicationsIt is not a defense to say that the submission of a false application was unintentional. See Mi Farmacia v. DMAHS, HMA (April 20, 2008).Failure to investigate and verify information equivalent to a willful failure to provide truthful response. See Surgi-Med v. DMAHS, HMA (August 25, 2006).Questions on application increasingly complex
28 MFD – What to ExpectAs of January 1, 2011, MFD will perform a pre-enrollment site visit for new applicants.New Providers will be subject to enhanced oversight, such as prepayment review and payment caps.
29 MFD – What to Expect 2011 Fiscal Year Objectives Addiction Services Adult Medical Day Care ServicesCharity CareChild Behavioral Health ServicesDME ProvidersHome Health ServicesLaboratory ServicesLock-In ProgramMedi-Medi Project
30 MFD – What to Expect 2011 Fiscal Year Objectives (con’t) Pharmacies Review of Purchase invoices1100 Pharmacy Audits/Year1200 DME Audits/YearDesk and Onsite AuditsReview Pharmacy Overrides
31 Patient Protection and Affordable Care Act (PPACA) – Background 2010 Healthcare Reform Act – goes into effect on January 1, 2011961 total pages of legislative textPortions have been challenged – Section 1501 (“Individual Mandate”)Section 6401 deals with fraud, waste and abuseAmends Medicare by adding new requirements regarding:Screening of providers and suppliersA provisional period of enhanced oversightDisclosure requirementsPayment adjustmentsTemporary enrollment moratoriaCompliance programs andRelated Fees
32 Screening of Providers Licensure checkCriminal background checkFingerprintingUnscheduled and unannounced site visits, including pre-enrollment site visitsDatabase checks (including such checks across States) andSuch other screening as the Secretary determines appropriatePPACA (Pub. L ), Sec. 6401(a)(3)(B)
33 Provisional Period of Enhanced Oversight The Secretary shall establish procedures to provide for a provisional period of not less than 30 days and not more than 1 year during which new providers of medical or other items or services and suppliers, as the Secretary determines appropriate, including categories of providers or suppliers, would be subject to enhanced oversight, such as prepayment review and payment caps.Id.
34 Increased Disclosure Requirements A provider of medical or other items or services or supplier who submits an application for enrollment or revalidation of enrollment in the program shall disclose (in a form and manner and at such time as determined by the Secretary) any current or previous affiliation (directly or indirectly) with a provider of medical or other items or services or supplier that has uncollected debt, has been or is subject to a payment suspension under a Federal health care program (as defined in section 1128B(f)), has been excluded from participation under the program under this title, the Medicaid program under title XIX, or the CHIP program under title XXI, or has had its billing privileges denied or revoked.Id.
35 Compliance ProgramsRegulations not yet written but PPACA requires Secretary to establish core elements.MFD: strongly encourages providers whose payments from the Medicaid program exceed $100,000 per year to implement a compliance program.
36 Compliance ProgramsCompliance programs need to encompass billings, payments, medical necessity, quality of care, governance, credentialing and other risk areas that a provider, with due diligence, identifies.
37 Compliance ProgramsSpecifically, any compliance plan should include the following elements:Designation of a chief compliance officer responsible for the day-to-day operation of the compliance program.Training and education of all affected employees and personsTraining should occur periodically and should be made a part of the orientation of new employees A communication process for the reporting of compliance issues;Disciplinary policies and standards that are distributed to all employees including policiesFailing to report suspected problems;Engaging in non-compliant behavior;Encouraging, directing, facilitating or permitting either actively or passively non-compliant behavior.A system for routine identification of compliance risk areas including but not limited to internal audits and external audits
38 Processes a Pharmacy Should Have In Place Procedure to respond to data requests by CMS, MEDICs, and law enforcement, or their designees in a timely mannerProcess to find overpayments and underpayments and properly report and repayProcess to identify improper coverage determinations, services, or enrollment and properly report and repay1 MEDICs: Medicare Drug Integrity Contractor – An organization that CMS has contracted with to perform specific program integrity functions for Part D under the Medicare Integrity Program. The MEDIC is CMS’ designee to manage CMS’s audit, oversight, and anti-fraud and abuse efforts in the Part D benefit.
39 Processes a Pharmacy Should Have In Place (con’t) Process to identify claims submitted for drugs that were prescribed by excluded or deceased physicians and report and repayPolicies that stress confidentiality, anonymity, and non-retaliation for compliance related questions or reports of potential non-complianceProcedures to correct underlying problems that produce Medicare Part D violations and prevent future misconduct.
40 Processes a Pharmacy Should Have In Place (con’t) Procedures to keep records that document any and all corrective actions and follow-up compliance reviews for future health oversight purposes and/or referral to law enforcement, if necessaryProcess to comply with the ten-year record retention requirement1A commitment to Pharmacy & Therapeutic Committee decisions made by considering clinical efficacy and appropriateness of formulary drugs over cost1 See 42 C.F.R. § (d).
41 Processes a Pharmacy Should Have In Place (con’t) A bay audit program in which the pharmacy’s dispensing area is divided into 4 separate sections and audit one section every weekProcess to purge Will Call Bin of all prescriptions greater than 14 days old (Contact patient and remind them to pick up prescription, and if patient declines to pick up prescription, return it to stock and reverse the claim)
42 What This Means for Pharmacies Keep a complete back up of all the pharmacy’s files off site on a daily or weekly basisReview RAS promptly and correct all issuesRepay promptly prescriptions not picked up by a patient or not authorized by a physicianReport any issue regarding irregular prescriptions promptlyCreate a policy assuring a 10 year record retention policy
43 Internal AuditsAudits should include a review of documentation including:PrescriptionsInvoicesPharmacy licensesClaim transaction recordsSignature logsPurchase recordsNegotiated prices
44 Internal Audits (con’t) Audits should also verify:That pharmacies are in compliance with minimum state pharmacy practice standardsThat pharmacies post or distribute notices to patients to contact their plans if they want to question coverage information provided by pharmacistsContracts with pharmacies and rebate and discount agreementsChief Compliance Officer should also conduct interviews with the pharmacy staff to gauge whether applicable Medicaid and Part D requirements are being followed
45 What This Means for Pharmacies Do self monitoring audits on a regular basis so potential issues can be dealt with before a formal auditDo spot checks on inventories to make sure they match up with purchasesDo spot checks to verify proper NDC numbers are being usedDo spot checks to verify prescriptions comply in all respects with Federal and State law
46 Monitoring TrendsTo monitor trends and patterns, pharmacies should generate or receive and review reports such as the following:Payment reportsDrug Utilization ReportsPrescribing Patterns by Physician ReportsGeographic Zip Reports
47 Monitoring Trends Information may be available from Pharmacy software Employee ObservationsWholesalersGovernment Entities (DEA, Medicaid, Medicare)
48 Medicare ZPIC Audits Zone Program Integrity Contractors (ZPIC) Conduct post and prepay audits as a way of curbing improper Medicare paymentsBurden of proof shifted to provider who must provide documents before getting paidprogress notes, medical history, pictures of service, purchase invoices, assessment records90 to 120 days waiting periodThe new ZPIC covers seven zonesAs of November 2010, CMS had awarded four ZPIC contracts, with three more contracts planned.CMS issued lucrative contractsAdvance Med Corporation was awarded a $107,957, five-year contract for Zone 5. (Healthcare Finance News, 9/3/2009)
49 Medicare ZPIC Audits“CMS pays 4.8 million Medicare claims each day, approximately 1.2 billion Medicare claims each year. Nevertheless, with the new tools provided to CMS under the Affordable Care Act, we are steadily working to better incorporate fraud prevention activities into our claims payment and provider enrollment processes where appropriate. . . All of these new authorities and analytical tools will help move CMS away from its historical “pay and chase” mode towards a closer alignment with strong fraud deterrents and increased enrollment screenings, new disclosure and transparency guidelines, and early identification of high-risk providers and suppliers.” - Dr. Peter Budetti, JD, Deputy Administrator and Director, Center for Program Integrity, Testimony before Congress, September 22, 2010.
50 Medicare ZPIC Audits“Five ZPICs will concentrate on fraud ‘hot spots’ in FL, IL, TX, NY and CA where we know the program has the greatest vulnerabilities.” - Deborah Taylor, Acting Director and Chief Financial Officer, Testimony before Congress, April 22, 2009.
51 ZPIC Audits (con’t) The ZPIC contracts include all claim types: Part A, Home Health, Hospice, Part B, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Managed Care (Part C), Part D Medicare Prescription Drug, and Medicare and Medicaid Data Matching.Target both the medical necessity of a claim and coding errors.ZPICS look at billing trends and patterns, focusing on providers whose billings for Medicare services are higher than the majority of providers in the community.
52 ZPIC Audits (con’t)Auditors can arrive unannounced, demand medical/ prescription records, and interview both providers and beneficiaries.Conduct pre-payment and post-payment reviews.They can be disruptive, time consuming and expensive.
53 ZPIC Audits (con’t)Extrapolation of damages utilized. See Sec of CMS’ Medicare Program Integrity ManualChaves County Home Health Services v. Sullivan, 931 F.2d 914 (D.C. Cir. 1991),Before an auditor can employ extrapolation, there must be either a determination of a sustained or high level of payment error, or documentation that educational intervention has failed to correct the payment error. Sec 935 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003
54 ZPIC Audits (con’t)Cases of potential fraud will be referred to the Office of Inspector General (OIG) for consideration and possible initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions.
55 Responding to a ZPIC Audit What can you do?Internal review of requested claims. The value of internal analysis vs. risk of creating a non-privileged paper trail of identified problems. Review past claims auditsReview the reasons given for each denial.Has the contractor correctly cited Medicare policy? Appeals must be filed in a timely fashion.
56 Responding to a ZPIC Audit If a provider is the target of ZPIC medical review, it should be assumed that it has been specifically targeted and the audit is not randomThis influences the manner in which a ZPIC request for records should be received and evaluated by the providerReview may include investigative techniques in addition to data analytics and claims review
57 Responding to a ZPIC Audit Stamp Date and Time ReceivedTrain staff on identity of contractorsEnsure that staff are aware of deadlines to submit recordsEnsure contractor is sending to the correct person/ addressSend certified mailKeep originals of documents
58 ZPIC Audits (con’t)The PSC or ZPIC BI [Benefit Integrity] unit or the contractor MR [Medical Review] unit shall identify the source of the random numbers used to select the individual sampling units. The PSC or ZPIC BI unit or the contractor MR unit shall also document the program and its algorithm or table that is used; this documentation becomes part of the record of the sampling and must be available for review.” (emphasis added)“The PSC or ZPIC BI units or the contractor MR units shall document all steps taken in the random selection process exactly as done to ensure that the necessary information is available for anyone attempting to replicate the sample selection.” (emphasis added)Section of CMS’ Medicare Program Integrity Manual
59 Audits by Government Government Action Prepayment Monitoring/ Withholding of funds42 C.F.R and N.J.A.C. 10: (d)Reliable evidence of fraud or willful misrepresentation by a providerRight to submit written evidence for considerationRight to a hearing
60 Pharmacist Obligations in a Government Audit Allow access to facilities as requestedFailure to do so may result in corrective actions (including intermediate sanctioning in line with 42 C.F.R. Subpart O)Allow access to records associated with Part D program for 10 years
61 What This Means for Pharmacies Pharmacies have rights to appeal audit findingsHearings, Fair Hearings, Due Process HearingsLimited time to appealImportance of Preserving Documents & CommunicationsHearings can be in front of an Administrative Law Judge (ALJ)
62 What This Means for Pharmacies Possible Criminal ExposureHealthcare Fraud and Medicaid Fraud are crimes potentially punishable by jail timeEach fraudulent claim can be a separate offenseCivil fines and remuneration can accompany criminal charges
63 Sponsor Fraud, Waste and Abuse Examples Payments for excluded drugsMultiple billingPayments for Part D drugs that are not for a “medically acceptable indication”Inappropriate formulary decisionsFalse information given to CMSBait and switch pricingBeneficiary is led to believe that a drug will cost one price, but at the point of sale is charged a higher priceInducing beneficiaries to sign up for specific drugs on formulary that are later removed
64 Pharmacy Fraud, Waste and Abuse Examples1 Inappropriate billing practicesIncorrectly billing for secondary payers to receive increased reimbursementBilling for non-existent prescriptionsBilling multiple payers for the same prescriptions, except as required for coordination of benefit transactionsBilling for brand when generics are dispensedBilling for non-covered prescriptions as covered itemsBilling for prescriptions that are never picked up (i.e., not reversing claims that are processed when prescriptions are filled by never picked up)Billing based on “gang visits,” e.g., a pharmacist visits a nursing home and bills for numerous pharmaceutical prescriptions without furnishing any specific service to individual patientsInappropriate use of dispense as written (“DAW”) codesPrescription splitting to receive additional dispensing feesDrug diversion1 See § of guidance
65 Pharmacy Fraud, Waste and Abuse Examples (con’t)1 Prescription drug shortingPharmacist provides less than the prescribed quantity and intentionally does not inform the patient or make arrangements to provide the balance but bills for the fully-prescribed amountIf there is insufficient quantity of medication to completely fill the prescription, should the fill the prescription as “cash” and dispense a three day supply at no charge. When a sufficient quantity of the medication is received, reverse the “cash” prescription and re-bill at the full amount and supply the difference between prescription full quantity and the amount givenPrescription refill errorsA pharmacist provides the incorrect number of refills prescribed by the providerSee § of guidance
66 Pharmacy Fraud, Waste and Abuse Examples (con’t)1 Prescription forging or alteringExisting prescriptions are altered, by an individual without the prescriber’s permission to increase quantity or number of refillsDispensing expired or adulterated prescription drugsPharmacies dispense drugs that are expired, or have not been stored or handled in accordance with manufacturer and FDA requirementsBait and switch pricingA beneficiary is led to believe that a drug will cost one price, but at the point of sale the beneficiary is charged a higher amount$4.00 Generic Program: Must make generic listing available for review and if a generic is no longer available for $4.00, it must be immediately removed from the list and patient must be informed of the change before dispensing1 See § of guidance
67 Pharmacy Fraud, Waste and Abuse Examples (con’t)1 Illegal remuneration schemesPharmacy is offered, or paid, or solicits unlawful remuneration to induce or reward the pharmacy to switch patients to different drugs, influence prescribers to prescribe different drugs, or steer patients to plansTrOOP2 manipulationWhen a pharmacy manipulates TrOOP to either push a beneficiary through the coverage gap, so the beneficiary can reach catastrophic coverage before they are eligible, or manipulates TrOOP to keep a beneficiary in the coverage gap so that catastrophic coverage is never realizedFailure to offer negotiated pricesA pharmacy does not offer a beneficiary the negotiated price of a Part D drug1 See § of guidance2 TrOOP: True Out of Pocket Costs: The amount a beneficiary must spend on Part D covered drugs to reach catastrophic coverage
68 Prescriber Fraud, Waste and Abuse Examples1 Illegal remuneration schemesPrescriber is offered, or paid, or solicits, or receives unlawful remuneration to induce or reward the prescriber to write prescriptions for drugs or productsPrescription drug switchingOffers of cash payments or other benefits to a prescriber to induce the prescriber to prescribe certain medications rather than othersScript millsProvider writes prescriptions for drugs that are not medically necessary, often in mass quantities, and often for patients that are not theirs. These scripts are usually written, but not always, for controlled drugs for sale on the black market, and might include improper payments to the provider1 See § of guidance
69 Prescriber Fraud, Waste and Abuse Examples1 Provision of false informationPrescriber falsifies information (not consistent with medical record) submitted through a prior authorization or other formulary oversight mechanism in order to justify coverage. Prescriber misrepresents the dates, descriptions of prescriptions or other services furnished, or the identity of the individual who furnished the servicesTheft of prescriber’s DEA number or prescription padThis information could illegally be used to write prescriptions for controlled substances or other medications often sold on the black market. In the context of e-prescribing, includes the theft of the provider’s authentication (log in) information1 See § of guidance
70 Medicare Beneficiary Fraud, Waste and Abuse Examples1 Misrepresentation of statusA Medicare beneficiary misrepresents personal information, such as identity, eligibility, or medical condition in order to illegally receive the drug benefit. Enrollees who are no longer covered under a drug benefit plan may still attempt to use their identity card to obtain prescriptions.Identity theftPerpetrator uses another person’s Medicare card to obtain prescriptions.TrOOP manipulationA beneficiary manipulates TrOOP to push through the coverage gap, so the beneficiary can reach catastrophic coverage before they are eligible.Prescription forging or alteringWhere prescriptions are altered, by someone other than the prescriber or pharmacist with prescriber approval, to increase quantity or number of refills.1 See § of guidance
71 Medicare Beneficiary Fraud, Waste and Abuse Examples1 Prescription diversion and inappropriate useBeneficiaries obtain prescription drugs from a provider, possibly for a condition from which they do not suffer, and gives or sells this medication to someone else. Also can include the inappropriate consumption or distribution of a beneficiary’s medications by a caregiver or anyone else.Resale of drugs on black marketBeneficiary falsely reports loss or theft of drugs or feign illness to obtain drugs for resale on the black market.Prescription stockpilingBeneficiary attempts to “game” their drug coverage by obtaining and storing large quantities of drugs to avoid out-of-pocket costs, to protect against periods of non-coverage (i.e., by purchasing a large amount of prescription drugs and then disenrolling), or for purposes of resale on the black market.Doctor shoppingBeneficiary or other individual consults a number of doctors for the purpose of inappropriately obtaining multiple prescriptions for narcotic painkillers or other drugs. Doctor shopping might be indicative of an underlying scheme, such as stockpiling or resale on the black market.1 See § of guidance
72 CMS Position on Self-Reporting “While self reporting of potential fraud is voluntary1, CMS believes that self-reporting of fraud, waste and abuse is a critical element to an effective program to control fraud, waste and abuse.”21 42 C.F.R. § (b)(4)(vi)(H)2 See §20 of guidelines
73 Useful Links Office of the Inspector General (OIG) www.oig.hhs.gov OIG Mailing ListOIG Fraud SiteOIG Exclusion SiteGeneral services Administration (GSA)CMSCMS Medicare Learning Network (MLN)CMS Mailing List