Medicaid fraud totaled around 12.9 million dollars in 2007 according to the U.S. Office of Department and Management. Medicare fraud was slightly less at $10.8 billion. Though this number may sounds shocking a fair amount of this may actually be due to the Medicaid and Medicare itself.
Near the close of business today I had a phone call come in from a patient's parent asking us to refill her son's necessary medication. I obliged and went about my regular duties while my technician filled prescriptions and did other small tasks. Withing 30 minutes of calling a woman showed up to pick up the prescription that was phoned in for a refill. I looked up the desired prescription and saw it was in troubleshoot due to an insurance problem. This is where it the government based programs ALWAYS get something wrong.
I opened the prescription on and saw that the problem was that Medicaid claimed the prescription was not properly billed to the child's correct primary insurance. To clarify his parent were divorced and his mother had custody BUT his father had insurance that still covered him and therefore must, by law, be billed previously before billing Medicaid. I double check with the patient and I had all of the correct information in the system. I fiddled with some rejection issues for billing 2 different insurances that I have picked up along the way. Still to no avail.
This means I have to face every pharmacists nightmare. The dreaded insurance call...
I got through amazingly quick (probably because who the hell is filling prescriptions on a Friday nigtht that isn't a pain med or possibly birth control). When I get through I am connected with Gino who was surprisingly pleasant throughout the call, unlike most people who I reach when calling Medicaid. I explain to him the problem, that the insurance is being billed correctly yet I can not get Medicaid to cover the rest. Gino gives me several more options that I did not previously try but all are futile.
Then it dawns on me.
I can go back and see how the prescription was billed previously. As I pull up how this prescription was previously billed I mention it aloud to Gino. Gino says, "Well that makes sense since that was the billing number that kept coming up on my screen." There is one major problem though. With the way I am billing this rather expensive prescription I am telling medicaid that I am actually billing a different insurance company than I am and I am also saying that I did not collect payment from the primary insurance. Basically I am telling Medicaid that I am not getting paid for this and they need to pay it in full.
This is Medicaid fraud by the book!
"Wow, you're right! My system is saying that's the only way we can cover this prescription but they are literally telling me to falsely file this claim!" I ask Gino to leave a detailed message for his supervisor and he gladly obliges. I can actually he him scuttering around papers and pens to start writing. I stated to him the only reason I am doing this is because 1. it's in the best interest of the patient and 2. he told me to. He agrees and says he will send the tapes on to his superiors as well. We exchange goodbyes and hang up.
The woman who was sent to pick up the child's prescription is staring at me now with her mouth agape. "Wait, so Medicaid told you to committ fraud? What the hell?" "My sentiments exactly," I replied. The woman then went on a tirade and starting laughing about how she couldn't believe it but was not about to complain since the child definitely needs the medication. I agreed with her but what was I to do since I was instructed by Medicaid?
As I go to ring the woman out I ask for the patient's date of birth. "I think it's... I don't know we all have too many kids," states the man she is with. Seriously, now Medicaid patients are admitting they have too many kids!?!?! I can't believe my ears! After hearing this I half expected some hell spawn to appear from behind the pharmacy counter but thankfully it did not. The woman gave me the correct info and was glad I could help and planned on contacting her social worker.
This child had several prescription, all costing in the hundreds of dollars, that had been filled for over 6 months like this! The only way this could have happened is if somebody called Medicaid to get the override and repeatedly billed it that way. I can only imagine how many times Medicaid has told other pharmacies to fraudulently bill them in similar situations. With that being said it is now wonder why so many government programs are in the red or that Medicaid fraud is around $12.9 million. When an average guy from a small town with a little common sense can prove how there is a major loophole in a system designed by "well educated" politicians who make careers out of setting up these programs it is no wonder our medical system is "broken". Maybe if somebody high up in the Medicaid or government reads this I can get a consulting job in which they will pay me millions once I prove I can save them billions.
Mr. President Obama, I think I just got you a few more bailouts so how about...
Posts
No comments:
Post a Comment