Medicare Compliance & Reimbursement

Big players in the pharmaceutical industry have borne the brunt of most Medicaid prescription drug fraud enforcement - but doctors, pharmacists and Medicaid recipients themselves are in the cross-hairs in Florida, where state prosecutors maintain criminals are using Medicaid to finance black market drug operations.

Florida Attorney General Charlie Crist is vowing to get tough after the release Dec. 18 of a statewide grand jury report on recipient fraud in the Medicaid program. The report, which includes details of "professional" Medicaid recipients diverting millions of dollars of prescription drugs - such as painkillers and HIV medications - to street buyers, outlines a network of schemes that is tantamount to drug-dealing at taxpayers' expense, Crist says.

According to the report, recipients receive prescriptions based on real or falsified illnesses, often from doctors terminated from the program. The pharmacies in turn bill Medicaid and the recipient resells the drugs to illegal wholesalers. The report described one instance where $300,000 in Medicaid drugs was resold in one transaction.

From 2002 to 2003 the Medicare program suffered a similar fate, paying nearly $100 million for five intravenous infusion drugs in Miami-Dade County alone, an earlier study says.  

"There are many facets to this problem," says James McDonough, Florida's top drug enforcement officer. "Among other things, resolution requires legislative solutions that focus on doctors, pharmacies and recipients."

Among the recommendations to the legislature were criminalizing the resale of Medicaid-paid drugs by recipients, giving the state Medicaid agency more power to manage and/or terminate recipients suspected of abuse, and prohibiting reimbursement to non-Medicaid providers.

To see the report, go to http://myfloridalegal.com/interimjury17.pdf.