Unauthorized Prescriptions Not Medicare Fraud – Program Pays Anyway

Study Finds Medicare Pays for Unauthorized Prescriptions, Leading to Questions about Medicare Fraud Monitoring


On June 25th, the Inspector General of the US Department of Health and Human Services released a study that identified more than 417,000 unauthorized or potentially fraudulent prescriptions paid for by the Medicare program since 2009. That included both initial prescriptions and refills from pharmacies. The study has led to serious questions about Medicare fraud and the program’s ability to monitor abuse of its services.

The study found that 30,000 prescriptions were for painkillers and other drugs that are easily addictive, and which appeared to be prescribed by dieticians, chiropractors, massage therapists, and interpreters, who may or may not also be licensed physicians.

All of the questionable prescriptions totaled $31.6 million in Medicare expenses. The drug spending program, Part D, spends far more money annually on prescriptions than that. However, the amount does raise serious questions about Medicare fraud, and how the program tracks physicians and prescriptions.

“In a prescription drug program like Part D, $31 or $32 million may not sound like a lot, but every little bit adds up,” said Sen. Tom Carper, D-Del., chairman of the Senate Homeland Security and Governmental Affairs. “We don’t have the money in Medicare to be wasting for this area.”

The panel has scheduled a hearing about the potential Medicare fraud and prescription monitoring. Prescription abuse and Medicare fraud cost the program $62 billion last year.

Jennifer St. Sauver, Ph.D., the study author said, “Often when people talk about health conditions they’re talking about chronic conditions such as heart disease or diabetes. However, the second most common prescription was for antidepressants — that suggests mental health is a huge issue and is something we should focus on. And the third most common drugs were opioids, which is a bit concerning considering their addicting nature.”

On Thursday, June 20th, the Inspector General also identified more than 700 doctors with questionable and potentially dangerous prescribing patterns, so this is the second time in less than a week that the DHHS has called out Medicare for its fraud monitoring strategies.

That report focused on 2,200 whose records stood out for at least one reason: number of prescriptions per patient, brand name drugs, painkillers and other addictive drugs, or the number of pharmacies who dispensed their orders. Of those 2,200, 736 were flagged as “extreme outliers,” raising questions about potential Medicare fraud. For example, 24 of those doctors wrote more than 400 prescriptions, filled without question, for one patient (the average doctor writes 13 per patient). In another instance, a doctor in Illinois had prescriptions filled by 872 pharmacies spanning 47 states, and Guam.

The “extreme outliers” by themselves cost the Medicare program $352 million.

It is possible that these prescribing patterns are not Medicare abuse. The pharmacy could have mistakenly attributed the prescription to an unlicensed physician. It could also be that, while a medical professional primarily identifies as a dietician, for example, they could also be a licensed physician – weaknesses in the Medicare database make that information difficult to uncover.

However, the Centers for Medicare and Medicaid Services (CMS) said some of the examples in the report are due to other weaknesses in the federal database which can, in fact, lead to Medicare fraud and unauthorized prescriptions.

An agency spokesman said that the program is working hard to fix the database to better track potential Medicare fraud and abuse.

The Strom Law Firm Protects Medicare Fraud Whistleblowers in South Carolina

If you have first-hand knowledge of government fraud occurring at your place of employment or your doctor’s office, including Medicare fraud, the attorneys at the Strom Law Firm can help protect your rights. In order to help the government provide the best possible services, Medicaid and Medicare fraud must be reported as soon as possible. The attorneys at the Strom Law Firm understand the complexity of qui tam and whistleblower suits, and we offer free, confidential consultations to discuss the facts of your case. Contact us today.803.252.4800

About Pete Strom

Defending criminal charges including drug crimes, DUI, CDV, mail fraud, wire fraud, bank fraud, computer crimes, money laundering, and juvenile crimes, Pete also handles Federal and State investigations. Representing individuals in Civil Matters including Class Actions, Personal Injury, Qui Tam Actions, Defective Products, Nursing Home Neglect, and Professional Licensing Defense cases. Joseph Preston “Pete” Strom, Jr., the managing partner at Strom Law Firm, L.L.C., has been fighting for justice since 1984.

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