Medicare and Medicaid Fraud Conducted by Criminals Posing as Pharmacies

 Medicare and Medicaid Fraud Conducted by criminals posing as pharmacies

Criminal enterprises are stealing millions from the health care system as they pose as pharmacies. federal officials say these so-called “phantom pharmacies” are billing Medicare, Medicaid and private insurance companies for fake prescriptions.

Pharmacy Scams Getting Out of Control

According to the Department of Health and Human Services (HHS), the scams are growing by the day. Shimon Richmond, a field agent with the HHS told CNN Money that the scams are “a huge issue for the department.”

While the department isn’t clear exactly how much money is being drained from the health care system as a result of the phantom pharmacy schemes, it says taxpayers and the health insurance industry as a whole are losing more than $60 billion a year.

Unfortunately, this increase in fraud is also contributing to rising health care costs, says the HHS.

How the Scam Works

According to experts, here’s how the scheme typically works:

1. Criminals use a legitimate address to establish a fake pharmacy business.
2. Using stolen doctor ID and patient insurance ID numbers, the scam artists will write fraudulent prescriptions for expensive drugs that were never prescribed or dispensed.
3. They submit the fake prescriptions for reimbursements to insurance companies like Medicare or Medicaid for large returns. A fake pharmacy can rake in anywhere from $2,000 to $8,000 in a single claim.

The HHS is pursuing hundreds of phantom pharmacy cases, but is having a tough time cracking down because the pharmacies operate quickly and quietly. The entire span of their operation could run in as little as 60 days before disappearing and popping up again somewhere else under a new address.

Regulators also say that because Medicare requires pharmacies to be reimbursed quickly, fake claims are often paid out before they’re validated. They say there are just not enough law enforcement officials to stop it all.

With the scam artists being extremely clever–and often receiving the help of trained health-care professionals who want in on the money–the HHS says its fight against phantom pharmacies is likely to be an uphill battle for years.

Man Robs Bank for $1 to Receive Medical Care in Jail

      Man Robs Bank for 1$ to Receive Medical Care In jail

A man so desperate for medical care that he was willing to rob a bank to go to jail is finally getting his wish this week: A doctor’s appointment. The 59-year old North Carolina convenience store clerk said his bank robbery of a mere $1 was his attempt to get the medical treatment he hadn’t been able to receive via the traditional route.

Man Desperate for Medical Treatment

James Richard Verone was not like most bank robbers who hide their faces, tote assault weapons and rush tellers to fill bags with money in hopes of making a quick escape. Verone casually walked into a Gaston, N.C. bank unarmed, handed the cashier a note demanding $1 then sat down and waited for police to show up.

His robbery attempt came with only one goal: Jail time for medical treatment.

After losing the job he’d held for 17 years as a Coca Cola deliveryman during the financial crisis and eventually taking a part-time position at the convenience store, he realized his medical problems–which included back and foot issues, carpal tunnel syndrome and arthritis–prevented him from doing his work effectively.

Then he noticed a protrusion on his chest that brought with it pain he said he couldn’t tolerate. Having no health insurance, he was unable to get the help he needed, so he decided to take matters into his own hands.

Verone Says Treatment in Jail Is Easier to Come By

On June 9, Verone mailed a letter to the Gaston Gazette, telling the newspaper of his plans to rob the bank. He listed his forwarding address as the Gaston County Jail. Then he hailed a cab to take him to RBC Bank where he handed the teller his $1 demand on paper and waited for the police to arrive.

He was indeed taken to jail and charged with larceny instead of bank robbery since he only attempted to “steal” $1. But the initial punishment landed him enough time to make an appointment with the jail doctor for Friday.

Verone’s original bond was set for $100,000 then was reduced to $2,000, but he doesn’t plan to pay it. He hopes to stay in jail for a few years and even plans to tell the judge that he will commit the crime again if his punishment isn’t severe enough. He explained that choosing jail was just the best of a bunch of bad options and he has no regrets.

He hopes before his sentence is complete that he will receive back and foot surgery and get the protrusion on his chest treated. When he is eventually released, he wants to collect Social Security and move to the beach.

Obama Administration Plans Undercover Survey on American Doctors

 Obama Administration plans undercover Survey on American Doctors

The Obama administration has announced its plans to conduct a survey on American doctors in the near future. The survey will be the government’s attempt to confirm reports of the difficulties people have when trying to obtain health care.

Survey to Address Issues in Health Care

According to the Obama administration, the survey will use undercover contractors who will pose as patients, unknown to physicians at various medical facilities. Some of the goals of this survey include:

• Addressing the critical shortage of primary doctors, including experts in internal medicine and family practice.
• Finding out if doctors accept patients with private health insurance and turn away those with government coverage, as noted in a recent study.

Ultimately, the Department of Health and Human Services–which proposed the poll to the White House–says it wants to use the survey to ensure that more than 30 million Americans who will acquire coverage under health care reform will have access to primary care doctors.

Doctors Against Secret Surveyors

Doctors have expressed displeasure with the idea of the secret survey, stating that the approach connotes a Big Brother tactic. However, federal health officials have assured the doctors that the result of the survey would be confidential.

The government estimates that the survey will initially cost $347,370 and is likely to go up over time. Hopefully, however, the answers gained will pay for themselves if health officials are able to ensure more Americans have access to quality health care.

Georgia to Allow Out-of-State Health Insurance Policies Starting July 1

  Georgia to allow Out of state Health Insurance Policies Starting July1

A new law in Georgia will allow state-licensed health insurance companies to sell policies offered across the nation that provide less coverage than the state requires. The new law is set to take effect on July 1 and is said to be among the first of its kind to be offered in the United States.

Policies Only for Individuals, Not Employer Groups

Under the new law, individuals in the state will have access to a larger number of policy options since they will be able to purchase from additional states. However, individuals who are currently insured by their employers fall into the category of group coverage and won’t have access to the policies.

Independent policyholders currently comprise only about 4 percent of the market in Georgia, according to the Kaiser Family Foundation. Because they are underserved, state lawmakers want to open up opportunities to this group.

It’s unclear how many insurance companies operating in the state will eventually offer plans. Currently, none are able to because the state insurance commissioner’s office has to write and adopt regulations that will govern the policies–a process that could take several months to complete.

Critics Say Law Could Open the Door for Watered-Down Policies

The debate of whether or not to offer health insurance across state lines has existed for many years. Most recently, Republican lawmakers proposed to have this provision added to health care reform prior to the law’s passage in March 2010. Their proposal was turned down.

Now that the law has been passed in Georgia, experts say it could drive prices down by introducing new competition and allowing roughly 20 percent of residents in the state to find a policy they can afford.

But critics of the law complain that taking this route could open doors for watered-down policies that don’t cover important services like mammograms, diabetes care or even regular checkups for young children that are required under Georgia policies.

The bill’s sponsor, state Rep. Matt Ramsey, says he is working to build in consumer protections that will address these concerns, including requiring out-of-state plans to carry a benefits chart outlining exactly what Georgians are getting for their money.

In addition, he says those who purchase the plans will still have access to the state’s dispute resolution process and Georgia courts, giving them the protections they need if they decide to take on an out-of-state plan.

Wal-Mart to Offer Free Legal Support to Medicaid Patients

         Wal-Mart to Offer free Legal Support to Medicaid patients

The nation’s largest retailer, Wal-Mart, recently announced  it will provide free legal support for Medicaidpatients and their families. This is the first time in the company’s history that it will be interacting with the government’s public health insurance system in this way.

Wal-Mart Partners with Arkansas Children’s Hospital

Wal-Mart has announced it will be partnering with the Arkansas Children’s Hospital to provide legal support to Medicaid patients free of charge. In the arrangement, Wal-Mart’s lawyers will take on the government and other entities to help sick children gain access to programs, equipment and services that they may have been denied under the program.

Jeff Gearhart, Wal-Mart’s general counsel, recently announced the company’s in-house team of 142 lawyers will help patients with a variety of issues associated with Medicaid. For instance, he noted lawyers might tackle Medicaid’s administrative and bureaucratic hurdles–the red tape patients encounter when visiting a hospital for care.

He explained lawyers will also be trained to help families navigate Medicaid in basic ways like filling out the right forms, as well as for more complex matters like procuring insurance for expensive treatments or medical devices like specialized wheelchairs.

Because the bulk of the cases attorneys will work on will be resolvable through due diligence and rarely require litigation, Gearhart said the company can work for a few hours of pro bono legal time.

Services Could Expand Medicaid Options for Families

Currently, the program is only being offered via the pilot project with the Arkansas Children’s Hospital. Gearhart said if the pilot is success, the company could expand the partnership nationwide so that it works with other hospitals, companies and law firms in a similar way.

This could be of great benefit to the large number of Medicaid patients who reportedly don’t have access to the same treatment options as patients with private coverage.

A report released in June by researchers in Illinois found that medical specialists were more likely to deny treatment to patients on Medicaid than those with private insurance largely due to the low reimbursement rates and delayed payments. The same was revealed a month earlier in a study conducted on dentists.

Wal-Mart has expressed hope that issues like this can be resolved through its free legal support while simultaneously providing patients with the knowledge necessary to make the most of their Medicaid coverage.