Medicare Part D provides additional opportunities for Medicare patients to have access to a less restricted array of beneficial drugs. Part D qui tam False Claims Act violations for whistleblower exposure have been identified including: billing for drugs not provided; billing for brand name drugs when generics are dispensed; billing for non-covered drugs as covered; billing multiple payers for the same prescription; splitting prescriptions to receive additional fees; failure to apply “maximum allowable cost” pricing to drugs; submitting claims for drugs that have expired; billing for prescriptions with false physician identifiers; billing for drugs dispensed without prior authorization; submitting claims for brand-name drugs when generics were dispensed; and submitting claims for quantities of drugs over approved limits. Manufacturer Part D fraud can also take the form of unlawful kickbacks to either the dispensing provider or the submission of false information in connection with its obligation under the Discount Program Agreement.
In addition, pharmaceutical fraud includes such additional practices as: a healthcare provider or pharmacy waives the patient’s copay amount and overbills the insurance plan to recoup the cost; a pharmacy bills for prescriptions that were not dispensed; prescription drug shorting by the pharmacy; i.e., billing for sixty tablets, but dispensing only thirty; a pharmacy adds unauthorized refills to prescriptions; drug diversion; and a pharmacy, beneficiary, or policy holder may forge or alter a prescription. Less often recognized forms of fraud include: a beneficiary or policyholder misrepresenting their personal information such as identity, eligibility, or medical condition in order to receive a benefit illegally; an individual steals or purchases a beneficiary’s or policyholder’s personal information to submit false or phantom claims to obtain the insurance benefit; a beneficiary or policyholder allows a third party to use their benefit information to obtain medication and/or medical services.
Medical equipment fraud is another source of criminal behavior that ratchets up the cost of medical care in the United States. The fraudulent practices include: failure to report adverse events, off-label marketing, and the provision of financial inducements/kickbacks. The usual origin of the fraud comes from pressure being brought to bear on company employees–particularly sales representatives–to produce results and to cultivate business—irrespective of the actual benefit or cost effectiveness for the patient or the insurance company.
The specific area of hospital fraud includes: inpatient, outpatient, and cost report fraud. Whistleblower cases related to these forms of violation of the False Claims Act exposing this system-wide fraud are increasing in numbers yearly.
Inpatient services must be medically necessary and constitute an appropriate level of care. Claims for patient admissions must be medically necessary, and implicit within the payment, is that patient discharges are not premature. Claims for inpatients must also avoid upcoding, unbundling of services, or contain duplicates.
The intentional manipulation of code assignments for outpatient hospital claims to maximize payments and avoid NCCI [National Correct Coding Initiative] edits constitutes fraud. Unintentional misapplication of NCCI coding and billing guidelines may also give rise to overpayments or civil liability for hospitals that have developed a pattern of inappropriate billing. OPPS [Outpatient Prospective Payment System] rules require hospitals to submit claims for all OPPS services provided at the same hospital, to the same patient, on the same day, unless certain conditions are met. The submission of multiple claims for OPPS services delivered to the same patient on the same day may violate the False Claims Act.
Patient transfers to certain post-acute care settings for certain designated DRGs [Diagnosis Related Groups] must be properly coded so that a hospital will receive a per diem transfer payment, rather than the full DRG payment, or the False Claims Act may be violated. Inappropriate transferring of patients between the host hospital and a hospital-within-a-hospital–such as a rehabilitation center–also runs afoul of the False Claims Act. Other outpatient hospital fraud can take the form of falsely coding hospital-affiliated entities and clinics, as “provider-based.”
Cost report fraud includes improper reporting of “pass-through” new technology and drugs, including costs not related to organ acquisition, and false calculations with regard to GME [Graduate Medical Education] and IME [Indirect Graduate Medical Education] costs.
The PPACA [Obamacare] is here to stay. Nothing the Republicans do to undermine funding or to repeal the law will survive a veto by President Obama, and by the time a new president takes office, far too many participants in the systems created by the law will be in place to tempt even the most egregious of politicians to attempt to create a massively unpopular major change. Instead, We the People can use our voting power to force serious changes which will be popular: control of insurance company powers of premium escalation and coverage decreases, establish panels of experts (mostly nurses) to award cash payments for losses suffered by patients who suffer adverse consequences of treatment rather than having to resort to entering malpractice suits which are eminently unfair all around, retaining the concept of punitive damages—the designation to be part of the ongoing panel work—but to place reasonable caps for such things as pain and suffering; abolish fee-for-service as the basis for payment and substitute coded value driven measures; establish fair medical malpractice insurance premium rates; create federal contributions to the training of medical care providers and control the level of income of those providers. And, last but not least, establish stronger, faster, more effective controls of waste, abuse, and fraud which will necessitate a larger policing force with a more powerful mandate to deal with wrongdoers. Failure to do those things, however unpopular they may be with the far right, will result in bankruptcy of the health care system and eventually even the nation.