The Med Diva

An insider's guide to Medicare Part D and more

Archive for the category “Medicare Fraud”

This Medicare article is not about Paul Ryan or Obamacare. It’s about a new Medicare rule for power wheelchairs.

Seven states will require a prior authorization process to get Medicare coverage for power wheelchairs and scooters.

For the past few days, my inbox has been bombarded with news about the Paul Ryan budget and its projected impact—good and bad—on Medicare. I’m not a political pundit and I don’t pretend to be one, so I have no intentions of joining the Ryan-Romney-Medicare bandwagon. What I do want to talk about are the real (i.e., known) issues that are going to affect Medicare beneficiaries now or in the very near future.

Although it was like trying to find a needle in a haystack, I found such a real topic yesterday, in an article from American Medical News.  It turns out that while everyone has been worrying about Mr. Ryan and his proposed budget plans, Medicare beneficiaries in seven states are actually going to have to wait longer than beneficiaries in other states to get Medicare coverage for their power wheelchairs or scooters. This news is for real.

Beginning September 1, 2012, and continuing thereafter for the next three years, the Centers for Medicare & Medicaid Services (CMS) will require prior authorization for power mobility devices prescribed in seven states: California, Florida, Illinois, Michigan, New York, North Carolina, and Texas. CMS is calling this a “demonstration project,” which they said will allow them to collect data that will be used to combat fraudulent claims for power motility devices.
Under the three-year project, providers in the seven states will need to send authorization requests and supporting documentation to a Medicare contractor when ordering power wheelchairs for patients. The contractor will review the request to ensure that it meets national and local coverage requirements. Contractor approval will be necessary before patients can receive the items.  

According to CMS, the prior authorization review process will take about 10 business days. Expedited reviews will be available when a patient’s health would be harmed without access to the power wheelchair or scooter.

Medicare power wheelchair fraud has been rampant in recent years. According to CMS, federal law enforcement agencies have prosecuted more than 600 cases representing almost $3 billion in fraudulent claims since 2009. The seven states chosen for this demonstration project represent more than 40 percent of power mobility device orders through Medicare.

I’m not totally sure that a prior authorization process is the right tactic to take here, although I do give CMS credit for trying new ways to control Medicare fraud. And hey, maybe if CMS saves enough money by reducing fraud, we won’t have to talk about a Paul Ryan budget plan anymore…I’ll leave it at that.


Do Medicare cover Viagra for erectile dysfunction? No it do not. (But sometimes it get screwed anyway.)

Medicare Part D gets screwedOne of the ways I stay on the top of the Medicare industry is by using Google Alerts to monitor the Internet for information about Medicare benefits and regulations. Each day I receive about three or four email updates from Google Alerts, which include links to news articles, blog posts, and miscellaneous Web content.

Although the news articles and blogs are always legitimate, the links under the miscellaneous Web category are almost always spam, with such gramatically-incorrect headlines as “Do medicare cover viagra?” or “Get you cialis with Medicare.” Inevitably, the links take me to some article or advertisement that has nothing to do with either erectile dysfunction (ED) or Medicare.

Just in case anyone is still falling for this spam, Medicare does not cover ED drugs – for the most part.

According to P.L. No. 109-91, section 103, amended section 1860D-2(e)(2)(A) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the Medicare Part D program does not cover ED drugs “when used for the treatment of sexual or erectile dysfunction.”  But here’s the catch (of course there’s a catch; we’re talking about Medicare): ED drugs such as Cialis®, Viagra®, and Levitra® are covered by Part D when prescribed for medically accepted indications other than sexual or erectile dysfunction (such as pulmonary hypertension).

Medicare has been screwed to the tune of $3 million

According to a March 2011 report from the Department of Health and Human Services Office of Inspector General (OIG), of approximately $133 billion in gross drug costs for the years 2007 and 2008, Medicare covered more than $3 million in drug costs for ED drugs approved for the treatment of sexual or erectile dysfunction. Part D should not have covered these drugs.

Based on the findings of the study, titled “Review of Erectile Dysfunction Drugs in the Medicare Part D Program,” the OIG recommended the Centers for Medicare & Medicaid Services (CMS) maintain a comprehensive list of ED drugs that have been approved by the FDA for the treatment of sexual or erectile dysfunction. The OIG also recommended CMS distribute this list to all Medicare Part D plan sponsors.

Although this news is two years old, so far I have yet to see this comprehensive list of ED drugs. I also haven’t seen any more reports of Medicare mistakenly covering these drugs. Hopefully this means that CMS has its act together despite the lack of a list. But then again, maybe these spammers who keep cropping up on my Google Alerts know something we don’t know.

What artificial limbs, wheelchairs, and penis enlargers have to do with Medicare fraud

Fraudsters bill Medicare for billions of dollars in wheelchairs, articial limbs, and other medical devices.

According to a 2010 report on CBS’ 60 Minutes, Medicare fraud, which is estimated to total about $60 billion a year, has become one of, if not the most profitable, crimes in America. This white-collar crime has even surpassed cocaine dealing as the major criminal undertaking in Miami, Florida.

More often than not, Medicare fraud occurs when someone operates a phony pharmacy or medical clinic from a cheap storefront office. According to the FBI, all one has to do is find or create a front man to get an occupational license, bribe a doctor or forge a prescription pad, and obtain a list of names and Medicare ID numbers of legitimate beneficiaries that the “pharmacy” or “clinic” can then bill the fake charges to.

If patient lists aren’t available, fraudsters simply recruit some real people to help out with the scam to steal money from the government (and the taxpayers). In Los Angeles, for example, the City of Angels Medical Center recruited homeless people off the street to fill their empty beds. The clinic offered them cash and drugs, plus clean sheets and three square meals a day. The clinic billed Medicare tens of millions of dollars for their stay and the homeless got a nice break from the streets.

Don’t just toss the EOB statement without checking it
But seriously, Medicare fraud is a major problem that is hurting all of us. As I wrote during Open Enrollment about Medicare fraud, it’s so important to be on the alert and carefully review and keep records of your health care visits, services, prescriptions filled, medical equipment provided, significant lab work, etc.

Here are just few of the more bizarre items that fraudsters have charged to Medicare on behalf of unsuspecting beneficiaries:
• Urine bags
• Wheel chairs
• Air mattresses
• Artificial limbs
• Penis enlargers

Yes, penis enlargers. In the most recent and more bizarre case of Medicare fraud, a Wheeling, Illinois man was sentenced to three years in federal prison for shipping unwanted penis enlargers to diabetes patients. Gary Winner, 50, admitted to purchasing enlargers for about $26 each from online sex shops and shipping them to beneficiaries through his medical equipment company, claiming the devices helped “bladder control, urinary flow and prostate comfort.” He then billed Medicare $284 for each one, bilking Medicare of more than $2.2 million.

So next time you get an Explanation of Benefits (EOB) statement in the mail, review it carefully and compare it to your receipts to make sure everything is correct – you never know what somebody may be trying to charge to your Medicare benefit.

Countdown to Medicare Open Enrollment: Day 4

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

Day 4:  Open Enrollment is open season on Medicare fraud

Yesterday I discussed the importance of being alert to Medicare fraud and scams, particularly this time of year when Medicare Part D marketing is in full swing. According to a 2010 Nightline investigation, Medicare fraud costsU.S.taxpayers more than $60 billion a year. Yes, billions with a “b.”

 To help you better identify fraud and protect yourself—and others—from being scammed, here are a few things to be on the alert for at all times:

  • You’re asked for money or for your personal information (e.g., Medicare
    or Social Security numbers, bank account number, credit card number, etc.) by someone pretending to represent Medicare, Social Security, and/or a Medicare plan sponsor.
  • Another person asks to use your Medicare prescription drug card to obtain drugs at the pharmacy.
  • You’re asked to sell your Medicare prescription drug card.
  • Several payers (insurance plans), including Medicare Part D, are billed for the entire cost of the same prescription.
  • Your Explanation of Benefits (EOB) statement or Medicare Summary Notice lists prescriptions for medications you are not taking or services that were not ordered by you or your doctor.

In addition to being on the alert, you should also carefully review and keep records of your health care visits, services, prescriptions filled, medical equipment provided, significant lab work, etc. It’s also important to file copies of any bills or notices from insurance companies, doctors, hospitals, pharmacies, etc., as well as your canceled checks. Then every time an EOB statement arrives in the mail, read through it carefully and compare it to your receipts to make sure everything is correct.

To learn more about you can help stop Medicare fraud, visit the U.S. Department of Health & Human Services and the U.S. Department of Justice’s Stop Medicare Fraud website. The site has answers to frequently asked questions, as well as important information to help you better understand your EOB statements and find out what to look for in these documents.

The Senior Medicare Patrol (SMP)

If you want to get even more proactive in the fight against Medicare fraud, consider becoming a volunteer with the Senior Medicare Patrol (SMP). SMP is a group of highly trained volunteers who help beneficiaries avoid, detect, and prevent health care fraud. There are SMPs in every state and many U.S. territories—to find the SMP nearest you, click here.

Countdown to Medicare Part D Open Enrollment: Day 5

Open Enrollment for 2012 begins on Saturday, October 15, and ends on Wednesday, December 7, 2011.

Day 5: Beware of Medicare…Medicare scams that is, this time of year

When Medicare Part D first started in 2006, professional scammers immediately jumped on the bandwagon. They started by devising clever ways to trick seniors into giving them money or other information that would allow the scammers to access their bank accounts. For example, in the “$299 Ring” Scam (see video), callers would identify themselves as Medicare employees and ask for checking account information in order to “sell them a Part D drug plan for $299.”  Other scammers called Medicare recipients and told them they would deposit money into their bank accounts if they provided their account numbers. They would also ask them for their Social Security numbers and threaten them by saying they would lose their Medicare coverage if they did not provide this information.

Fortunately, most people were leery of the callers and notified either the Centers for Medicare & Medicaid Services (CMS) or other local authorities. Many of the calls were traced to phone numbers outside  the United States.

According to CMS, you should always call your local police if you receive a call from an unknown person and are asked to provide personal information over the telephone. Here are some other helpful tips from CMS to keep top of mind, especially during the Open Enrollment period, when professional scammers know you may be searching for a new Medicare plan:

  • Protect your Medicare number. This number is as important as your Social Security number, credit card information, computer passwords, etc. Never give your card or number to anyone—not only is it illegal for someone else to use your card or number, it can lead to identify theft. And if you card is lost or stolen, report it right away to Social Security.
  • If you don’t trust, don’t talk. Only give out your personal information to people or organizations you trust, such as your doctor, trusted friend or family member, attorney, accountant, government organization such as Social Security, or a Medicare-approved plan. (Once you decide to enroll in a Medicare plan—or you decide to switch plans—you will need to provide your Medicare number to the plan.)
  • Never join a plan over the phone—unless you initiate the call.
  • Know the marketing no-no’s. There are many things that Medicare prescription drug plans and the people who represent them cannot do. For example, they can’t:
    • Charge you a fee to join a plan
    • Come to your home uninvited to try to sell you a plan
    • Offer you cash, free meals, or other gifts while trying to sell a plan to you
    • Enroll you into a plan over the phone unless you call them and specifically ask to be enrolled
    • Ask you for payment over the phone or Internet (they must send you a bill)
    • Try to sell you other products other than the plan you agreed to hear about
    • Try to enroll you in a plan during an educational conference or health fair

If you think a plan or plan representative has broken the rules, or you believe you have received a phone call or e-mail from a professional scammer, you should report the incident to Medicare by calling 1-800-MEDICARE (1-800-633-4227);  TTY/TDD: 1-877-486-2048.  Not only will you help CMS to alert others to the scam or tactics, but you will also be playing a very vital role in reducing Medicare fraud.

Tomorrow, I’ll give you some more tips on helping to reduce Medicare fraud, waste, and abuse.

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