HIV Drugs for Deceased Beneficiaries Paid by Medicare, Finds Inspector General By Tod Aronovitz | 11/18/14 | 0 Comment

Coming across unintended data when Health and Human Services investigators—who were looking at Medicare coverage for patients prescribed AIDS drugs even though they had no HIV diagnosis—discovered that Medicare also paid for HIV drugs for deceased beneficiaries.

A recent report released by the Health and Human Services Department’s inspector general revealed that the Medicare rule does indeed allow for payment of prescriptions filled up to 32 days after a patient’s death.

According to an AP story, this peculiarity is not only at odds with the program’s basic principles, but will now be overhauled based on investigators’ recommendations to restrict or eliminate the policy.

In the report, investigators examined claims from 2012 for HIV medications—just a small slice of the overall Medicare drugs prescribed.  They subsequently cross-referenced their results with death records and found the program paid for drugs for 158 beneficiaries after they were already dead.  As a result, taxpayers paid $292,381, an average of $1,850 for each beneficiary.

The report uncovered that of the 348 HIV prescriptions dispensed for dead beneficiaries, nearly half were filled more than a week after the patient died and sometimes even multiple prescriptions were filled on behalf of a deceased individual.

On top of that, investigators don’t know what happened to those medications. It is believed many are diverted to the underground market, since HIV drugs can be targets for fraud because of their high cost, the report said.

Included among the examples:

  • Medicare paid $1,200 for a prescription for a 90-year-old Boston-area beneficiary dispensed 25 days after he died. The man had no history of HIV in his Medicare record.
  • On a single day, a Miami pharmacy filled a prescription for an 80-year-old beneficiary 16 days after he died. Medicare paid $1,800 for two HIV drugs. The pharmacy then dispensed the same two drugs on behalf on an 81-year-old woman who died 10 days earlier. Neither had a history of HIV in their Medicare records.

Although the report did not figure out the potential financial impact across the $85 billion-a-year Medicare prescription program known as Part D, investigators think there may be millions of dollars in waste.

“The exposure for the entire Part D program could be significant,” said Miriam Anderson, team leader on the report. “The payment policy is the same for all drugs, whether they are $2,000 drugs to treat HIV or $4 generic drugs.”

Medicare provided a formal response, agreeing that changes are necessary.

“After reviewing this report, (Medicare) has had preliminary discussions with the industry to revisit the need for a 32-day window,” wrote Marilyn Tavenner, the Obama administration’s Medicare chief.

Medicare originally tried to explain the discrepancy, deeming that the date of service listed in the billing records could be attributed to when a pharmacy actually submitted bills for payment. That billing date may have occurred after a prescription was filled, since some nursing home and institutional pharmacies submit their bills in monthly bundles. However, investigators found that about 80 percent of the prescriptions for dead beneficiaries were filled at neighborhood pharmacies, challenging what Medicare initially maintained.

How to Report Miami Medicare Fraud

Healthcare professionals or medical billing employees who have knowledge of questionable Medicare billing practices can file a confidential legal claim under the False Claims Act. By acting as a “whistleblower” in what is known as a “qui tam” lawsuit, a private party may collect up to 30 percent of the amount recovered, depending on how the case is prosecuted.

ARONOVITZ LAW: Miami Whistleblower / Qui Tam Law Firm

The Miami Qui Tam law firm of ARONOVITZ LAW routinely works with whistleblowers to document Medicare fraud and other forms of fraud against the government. Contact Miami Whistleblower / Qui Tam lawyer Tod Aronovitz to discuss your case.