Medcaid Fraud May Be Legal, As Long As You Get Their Permission

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...

When Trying Hard Bites You In The Butt... You Must Be A Pharmacist!

As a pharmacist there are many, MANY times that you can see a problem coming. One of those moments is when someone comes in with a stack of prescriptions. This is especially true when the said patient brings in the stack after 5pm, in which case if there is a problem you are usually stuck with nobody who knows what is going on to talk to in case there is an issue. This can leave you in quite a precarious point, do what is legal or do what is best for the patient. Rarely can you do both in retail pharmacy. This is the stuff they DON'T teach in pharmacy school!

A patient comes in with a rather panicky look on her face at ~1 1/2 hours before my pharmacy closes. The patient states to the technician that she is worried if we have enough of one medication in stock. She nervously says, "I wanna know if you have this medication 'cause most other pharmacies haven't had it in! He just got out of the hospital and really needs it!" From this I have determined that my actual patient is this person's father, who is just stabilized enough to leave a major hospital (at the point in which he has been there too long for their tastes and must be discharge ASAP so they can quit bleeding money away on him). This is not a rip on hospitals but the unfortunate truth of how insurance and mainly the Medicare system reimburses these hospitals, which is another story in and of itself.

I read the main prescription of concern and see it is for Lovenox 50mg inject one syringeful subcutaneously twice daily. Two glaring problems here: 1. Lovenox is expensive and 2. It does not come in 50mg! Or for that matter, Lovenox comes in no combination that can equal 50mg. This forces me to call the hospital which the patient just left and try to get a clarification of the prescription. Since one of the many residents at this facility wrote the prescription it is very well possible that the dose is wrong, the resident has no clue what strengths are available or somehow there is serious communications error since it is obviously written for 50mg.

So I inform the patient's daughter and call...

I get a hold of the hospital operator and briefly explain to her the situation. She says no problem let me page the physician.

5 minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi, you were holding?" Obviously she has forgotten who I was or why I was holding. I repeat my problem to her. "Oh, you need the floor. Paging won't help you!" I thought to myself, well you suggested it and seemed certain I could reach the said physician.

5 more minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi this (blank), how can I help you?" Again, I explain my situation and that I need someone who can clarify this. "OK, let me get you someone."

5 MORE minutes of elevator music interrupted by boastful statements about the hospital later...

"Hi this (blank), I am a nurse. What can I do for you?" Yet again, I explain the problem with the way the prescription is written. This time I explain all I need is someone to confirm that the dose is 50mg and that I can go ahead and dispense the 60mg syringe with an explanation to only inject 5/6ths of it. The nurse says, "I don't know can you do that?" I explain that is simple they can just push out the first 10mg and then inject the rest and that I had talked with the patient's daughter who understands. "Well, how does that work?" asked the nurse. I repeat my previous statement with more depth to how injecting with the style of syringe works. "Well are you sure?" she asked again. "Yes ma'am, this is a simple syringe it is not an auto-injector and is VERY simple." "Oh, well as long as it's not an auto-injector that's fine," she states. "OK, ma'am, can I get your name to put on this?" "Oh, I can't authorize that let me get you the physician on the floor."

SLAP! I could not help but slap my forehead at this point. I have now explained my problem in one form or another 3 times and no one knows what to do or how to go about approving this. Mind you this is considered a good hospital by the accrediting bodies.

3 MORE minutes of elevator music interrupted by boastful statements about the hospital later...

"Hello, this is Dr. (blank), I hear you have a problem with a patients Lovenox dose." Finally, someone who I think can help me solve my problem (which at this point I think I should have taken the easy route and just filled it with what I knew the physician wanted but in accordance with company policy have called to ensure that the prescription is written correctly). I explain my situation and the physician pulls up patient's profile and says sure no problem and that I can fill it that way. "Thanks doctor, the patient was getting worried they might not get this after they watched me talk to so many other people in your hospital who had no idea who I needed to talk to."

I then scan in the prescription and attempt to fill it. There's a problem. The insurance will not cover this medication because the physician who wrote the prescription (and the one I called to authorize it) are both residents and do not have active NPI numbers. I look online through the national NPI sites. Nothing. I then inform the patient's daughter of this problem. She then says, "Oh, that's OK. Just give them a call tomorrow we have enough to cover us through Friday!"

WHAT!

Apparently, this woman thought it was fine if she decided to make this situation and emergency and she needed it now. After watching me talk to multiple people on the phone and bust my tail to get her the medication for her father, THEN she decides it is no longer urgent. People like this are a serious problem. They have such an entitlement complex that they feel it is acceptable to act like only they matter and their problems trump everybody what everybody else is dealing with. They cause delays in the process and are really a big reason why many pharmacies, that are not terribly busy, can have longer than expected wait times.

With that being said I have no regrets for doing what I did. I did my best for what I thought was a paitent in need. Many other pharmacists would have done a similar job. I know I made others have longer wait times for what is essentially a self serving person but I did not know that at the time. This is what makes pharmacists a different breed. We are the connecting point for solving medication problems amongst multiple doctors and getting the patient what they truly need. The necessary medication. Sometimes we go above and beyond, this is our professional touch that machines will never be able to replicate