By Mary Johnson, editor
You get them whenever you visit a doctor, or fill a prescription — Medicare's "explanation of benefits" forms. Often perplexing, many people never review them, let alone, try to figure them out. But you might be stunned if you do, especially if you discover drugs, medical equipment, or medical services that you never received were billed to Medicare.
Joyce Heap was in end stage Alzheimer's disease, and living at a nursing home run by an Armenian couple, when her daughter Denise spotted suspicious charges on forms from her mother's Medicare drug plan. Denise Heap went online to find out what the drugs were, and she discovered her mother was supposedly receiving medications for conditions she didn't have, like breast cancer, asthma, and emphysema. Heap was convinced that someone used her mother's identity to bill Medicare for more than $10,000 worth of medications in just three months.
After reporting her suspicions to Medicare and her mother's Part D insurer, and not getting much of a response, Heap contacted the Los Angeles County sheriff's task force specializing in prescription drug fraud. There she learned the drugs listed on her mother's explanation of benefits forms are among the most desired type in Medicare drug fraud schemes.
Heap's story is part of a major investigative series on Medicare drug fraud, by the independent, non-profit investigative news organization ProPublica. Reporters, using Medicare's own data, were able to identify scores of doctors whose prescribing within Part D followed known patterns of fraud. ProPublica's investigation found that "Medicare's system for pursuing fraud is so cumbersome and poorly run that schemes quickly siphon away millions." The stories are drawing a remarkable reaction from the normally snail-paced Medicare. The agency recently announced plans to better control prescription drug fraud, including new authority to revoke doctors' Medicare enrollment if patterns of abusive prescribing are found.
Denise Heap's experience illustrates the important role that seniors and their families have in spotting and reporting Medicare fraud. More than 36 million people have Medicare drug coverage, costing the government $62 billion in 2012. For more information about stopping Medicare fraud, visit www.StopMedicareFraud.gov or call 800-633-4227.
Sources: 'Let the Crime Spree Begin': How Fraud Flourishes In Medicare's Drug Plan, Tracy Weber and Charles Ornstein, ProPublica, December 19, 2013. Listen to this story on NPR.
"Caught Up In A Medicare Drug Fraud," Tracy Weber and Charles Ornstein, ProPublica, December 31, 2013.