More than a feeling…

Commentary, Medicare Set-Aside Blog, News and Events on August 1, 2013
Posted by Jennifer Jordan, JD, MSCC


Often when reviewing medicals for an MSA, we feel there is just no way these claimants are using the drugs indicated by the file. Yes, the physician did write the script, and yes, the carrier did pay for it, but something still just doesn’t add up. Well, it seems maybe there is some merit to that feeling after all.

On July 23, 2013, a Maryland pharmacy owner and two of his employees were indicted for insurance fraud and identity theft. Apparently they had monitored their customers’ usage quite closely and billed for any refills authorized, but unfilled or unclaimed. It is estimated that this scheme amounted to over $2.5 million in fraudulent claims to various health insurance programs, inclusive of Medicare and Medicaid. The parties involved face up up 10 years in prison and a $250,000 fine. In contrast, some of the physicians at a Maryland orthopedic practice bilked several million from a local workers’ compensation carrier through excessive over-utilization, however only paid a $30,000 fine and were sentenced to continuing education for ethics, billing practices, and pain management. I guess if you’re going to be a thief, either go to medical school or have enough sense to steer clear of Medicare?

Provider fraud is a huge cost driver definitely worth monitoring. While there is little we can do about the physician that insists his excessive care is in the best interest of his patient, we can at least act to prevent being charged for services not received or not necessary. For example, when the use of TENS units was in vogue, DME providers would have a carrier set up automatic home delivery for supplies and then continue to send them for years, even though the unit was never used, because the carrier had actively notify them to cancel the service. While seemingly insignificant on a monthly basis (no more than $50/month) compared to other costly pain treatments, these costs add up over time and more importantly, when aggregated over an entire book of business, could add up to substantial unnecessary expense for the carrier.


See the article here: Pharmacy Store Owner and Two Employees Charged with Health Care Fraud and Identity Theft