Questionable 2012 Medicare HIV Drugs Exceed $30 Million By Tod Aronovitz | 08/21/14 | 0 Comment

In a report recently published by the inspector general of the Department of Health and Human Services, Medicare spent more than $30 million in 2012 on questionable HIV medication costs, paid for by its prescription drug program known as Part D. The document, which focused on potential fraud and abuse of Medicare HIV Drugs for patients rather than doctors and pharmacies, found a series of oversights which led to potential dubious payments and fraud schemes, many of which took place in Miami.

The report specifically flagged 1,578 Medicare beneficiaries who received $32 million worth of HIV medications (not including patients who were taking Truvada, which reduced the risk of HIV infection). Of those patients, more than half had no diagnosis of HIV, had no records of laboratory tests to monitor the use of the drugs, and had not received any medical services from any of the prescribers, findings revealed. Beneficiaries in the inspector general’s analysis did not identify if they were complicit in the questionable activity or if their IDs had been used without their knowledge.

Some of the more blatant examples of fraud in Medicare HIV drugs highlighted in the report include:

  • A 48-year-old in Miami who filled HIV drug prescriptions at 28 pharmacies. The medications, which were worth $200,000—almost 10 times what an average patient gets in a year—were supposedly written by 16 health providers.
  • Two Miami pharmacies dispensed drugs to 321 flagged beneficiaries. Most were women with an average age of 74, 20 years older than typical patients receiving HIV drugs in Medicare. The two pharmacies collected more than $350,000 for the drugs.
  • A 37-year-old in Miami received $146,160 in HIV drugs in 2012. He received 16 different HIV medications in a single month.

“While some of this utilization may be legitimate, all of these patterns warrant further scrutiny,” the inspector general report said. “These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market. They may also indicate that a pharmacy is billing for drugs that a beneficiary never received or that a beneficiary’s identification number was stolen.”

As a result, the report raises new questions about Medicare’s management of Part D. According to a ProPublica series that we referred to on our ARONOVITZ LAW blog on July 23, lax administration has enabled doctors to prescribe substantial quantities of inappropriate medications, squandered billions on needlessly expensive drugs and exposed the program to widespread fraud. Part D cost taxpayers about $65 billion in 2013, ProPublica figured.

One issue is the “protected class” status assigned to HIV drugs by Medicare. Insurance companies paid to administer Part D for the government must cover those patients without question. This leaves a window of opportunity for potential fraudsters who try to exploit this special status.

Sometimes pharmacies bill for the drugs, do not dispense them, and then bill Medicare or private insurers for them again. Other times, beneficiaries may misuse HIV drugs for their psychoactive effects or for their ability to enhance the effects of some painkillers.

Although the amount of suspicious activity involving HIV drugs is comparatively small in relation to the overall usage, Medicare still paid $2.8 billion to supply HIV drugs to 135,500 beneficiaries in 2012.

Thirty-eight percent of questionable beneficiaries lived in Miami or New York, a rate three times the percent of patients receiving HIV drugs who live in those cities.

The inspector general recommended that the Centers for Medicare and Medicaid Services (CMS) take steps to inhibit fraud and control abuse of HIV drugs. The report suggested that health plans should be required to conduct audits looking for unusual patterns of HIV medication use and encouraged Medicare to expand the ability of health insurers to put controls in place and restrict certain beneficiaries to a limited number of pharmacies or prescribers.

CMS said it would be open to letting Congress enact laws limiting the number of pharmacies or prescribers for beneficiaries who appear to be abusing drugs or engaging in fraud.

To check how your doctor prescribes drugs in the Medicare program and compares with peers, ProPublica publishes a “Prescriber Checkup” tool.

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.