Fraud, Waste and Abuse


Healthcare fraud, waste and abuse affects everyone. We all end up paying the price for fraud, waste and abuse. While the majority of members and health care providers act honestly, there are a small percentage of individuals who take advantage of the system. According to the National Association of Health Care Anti-Fraud Association (NHCAA), an estimated $100 million is lost daily on healthcare fraud.

Blue MedicareRx (PDP) is committed to detecting, correcting and preventing fraud, waste and abuse. The following information is intended to assist you in identifying and reporting any suspected cases of fraud, waste or abuse related to your Blue MedicareRx (PDP) Medicare Part D prescription drug plan.

Definitions


Fraud - an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person.
Waste - the over-utilization of resources. Using more resources or services than is necessary.
Abuse - activities that are inconsistent with typical practices, and that result in an unnecessary cost to the Medicare program, or in reimbursement for services medically unnecessary or that fail to meet professionally recognized standards for health care.

Common Types of Fraud, Waste and Abuse

By pharmacies:

Pharmacy fraud takes on many forms, such as those noted in the examples below. One way for members to assist us in identifying pharmacy fraud is to be aware of the following types of fraud so that they can report any unusual activity or suspected fraudulent behaviors:

Inappropriate Billing Practices

  • Billing for non-existent prescriptions
  • Billing multiple payers for the same prescription (except as required for coordination of benefit transactions)
  • Billing for brand when generics are dispensed
  • Billing for non-covered services
  • Billing for prescriptions that are never picked up (i.e. not reversing claims that are processed when prescriptions are filled but never picked up)
  • Prescription splitting to receive additional dispensing fees
  • Accepting or offering kickbacks or bribes

Prescription Drug Shorting

  • Pharmacy provides less than the prescribed quantity and intentionally does not inform the patient but bills for the full amount

Prescription Refill Errors

  • Pharmacy provides incorrect number of refills prescribed by the prescriber

Illegal Remuneration Schemes

  • Pharmacy offers, or pays, or solicits bribes or kickbacks to influence persons to prescribe different drugs, or steer patients to pharmacies
  • Pharmacy waives copays to entice members to patronize their business

By members:

Blue MedicareRx (PDP) reviews member utilization and activities, and investigates potential fraudulent behavior in order to take appropriate actions. Member fraud can take several forms. Among the kinds of activities that constitute member fraud are:

Identity Theft/Misuse of ID cards

  • Person uses another person’s Medicare card to obtain prescriptions
  • Loaning or sharing ID cards with ineligible members in order to illegally receive the drug benefit

Prescription Forging or Altering

  • Person alters a prescription to increase the quantity or number of refills
  • Person creates a false prescription or alters a valid prescription to obtain drugs or benefits not prescribed

Doctor Shopping

  • Person consults a number of doctors for the purpose of inappropriately obtaining multiple prescriptions for narcotics painkillers or other drugs
  • Doctor shopping may be indicative of an underlying scheme, such as stockpiling or resale of drugs on the black market

Prescription Diversion and Inappropriate Use

  • Person obtains prescription drugs from a provider, possibly for a condition from which they do not suffer, and gives or sells this medication to someone else
  • Also can include the inappropriate consumption or distribution of a beneficiary’s medications by a caregiver or anyone else

Other types of fraud, waste, and abuse:

Blue MedicareRx (PDP) wants members to be aware of other types of fraud, waste, and abuse so that they can report any unusual activity or suspected fraudulent behaviors. Below are other potential fraudulent activities that should be reported.

Premium Billing

  • Receiving premium bills from a company or individual you do not recognize
  • Requests for upfront payment of premiums before enrollment

Broker Agent Marketing Schemes

  • Falsifying application data
  • Enrolling non-existent members
  • Sales of non-existent policies or plans
  • Accepting or offering kickbacks or bribes to entice members to enroll


What Can You Do To Protect Yourself

  • Always keep all personal information, such as your Medicare number and Social Security card, safe, just as you would a credit card or bank account number.
  • Never give personal information until you are certain that the person or product is approved by Medicare or Blue MedicareRx (PDP). Please Contact Us if you have any questions
  • Always review your Medicare Summary Notice (MSN) or Explanation of Medicare Benefits (EMOB). Make sure your EMOB does not show prescription drugs you did not receive.
  • Don’t accept offers of money or gifts from providers for providing prescription drug services or to share your Medicare or Social Security number.
  • Educate yourself about the Medicare Prescription Drug Program.

How to report suspicious or fraudulent activity to Blue MedicareRx (PDP)

Blue MedicareRx (PDP) encourages members to report all suspected fraudulent activities. All reports are treated as confidential and will be investigated. You may make a report anonymously. Please include as much detail as possible (e.g., dates and times, names, address, specifics about alleged fraud or abuse).

To notify Blue MedicareRx (PDP):

  • Contact the Blue MedicareRx Fraud Hotline at 1-888-277-4149
    TTY/TDD, at: 711. This number requires special telephone equipment. Calls to this number are free.
  • Email: Medicare.Fraud@caremarkrx.com

For more information
Learn more about reporting fraud, waste, and abuse at Medicare’s website.


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