Medicare paid out $32 million for HIV drugs two years ago. However, a new report from the Office of Inspector General of the U.S. Department of Health and Human Services says that about 1,600 of those beneficiaries showed signs of fraud.
Some people who received HIV drugs from Medicare showed no signs of having HIV in their Medicare medical history, the report says. Some had prescriptions for overly large supplies of the medication; some redeemed their prescriptions for HIV medication at a large number of pharmacies; and some had prescriptions for HIV and also prescriptions for drugs that should not be taken with HIV medication.
The report gave several examples of suspected HIV drug fraud in the Medicare system. One 77-year-old woman in Detroit received $33,536 worth of HIV drugs from Medicare in 2012. Even though she had no record of HIV on her Medicare record, she was receiving 10 different types of HIV medication prescribed by six different doctors. There were no records that she had visited any of the doctors who had prescribed her the drugs.
Another person received $17,509 worth of HIV drugs in a single day in 2012, but did not get any HIV drugs for the rest of the year. She was prescribed more than twice the recommended dose for each of five different HIV drugs, even though two of the drugs (Atripla and Complera) are complete medications and should not be taken with any other HIV drugs.
These are troubling signs of abuse of the Medicare system.
"These patterns may indicate that a beneficiary is receiving inappropriate drugs and diverting them for sale on the black market," the OIG says. "They may also indicate that a pharmacy is billing for drugs that a beneficiary never received or that a beneficiary's identification number was stolen."
After the story broke, a Medicare spokesperson told WSJ that Medicare "takes this problem seriously and is taking steps to protect Medicare beneficiaries and the Medicare Trust fund from the harm and damaging effects associated with prescription drug fraud and abuse. We will continue to provide training to Part D sponsors on Part D proper payment and data submission, establishing formal outreach for prescription documentation, and conducting further analysis on plan reporting of rebates."
The spokesperson also said that Centers for Medicare and Medicaid Services (CMS) "will reiterate and clarify this guidance to sponsors with respect to the potential overutilization, misuse, and safety issues related to HIV drugs" and "will conduct future analysis that will use Medicare Part A and B claims data to identify beneficiaries, as well as the pharmacies and prescribers linked to these beneficiaries, to monitor fraud, waste, and abuse in Medicare Parts C and D."
