Alleviating Confusion and Preventing Fraud: PREVENTING FRAUD
Responsibility for fraud prevention belongs to everyone, especially health care professionals who care for the frail elderly. These professionals are the first people to whom their older patients turn for advice. For this reason, health care providers need to recognize fraud and should advise their patients appropriately.
Besides answering their patients’ questions about fraud, these professionals can play a major role in educating older patients so that they do not become victims. Education should consist of taking steps to prevent identity theft and encouraging patients to join a plan that provides access to needed medications. The CMS can also work to reduce the level of confusion surrounding the number and variety of PDP designs. antibiotics online pharmacy
In 1999, Medicare launched a major campaign to combat fraud under the banner “Who Pays? You Pay.” Medicare offered classroom training to 10,000 of its beneficiaries and volunteers from the American Association of Retired Persons (AARP). The sessions were intended to show them how to question their health care bills in order to reduce unnecessary spending, for example, making sure that they received the services or products that were paid for, and that the doctor ordered, and determining whether the products or services were appropriate for their diagnosis and treatment.
Even before that program was unveiled, the Clinton administration had focused unprecedented attention on the fight against fraud, abuse, and waste in a Medicare program called “Operation Restore Trust,” also known as the Senior Medicare Control Project. This model has been successful in recovering funds. Regional centers in various communities provide outreach opportunities for citizens to learn more about Medicare and Medicaid programs.
Today, the MMA plans to accomplish fraud prevention by having the CMS work with eight new Medicare Drug integrity Contractors (MEDICs) that possess specialized skills enabling them to detect fraud, waste, and abuse in the new PDP program. The eight MEDICs include the Delmarva Foundation; Electronic Data Systems, Inc. (EDS); IntegriGuard; Livanta; Maximus Federal Services; NDCHealth; Perot Systems Government Services; and Science Applications International Corporation. Their responsibilities are as follows:
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- analyzing claims data to discover areas in which fraud or abuse could be occurring
- investigating potential fraudulent activities involving enrollment, eligibility determination, or distribution of the prescription drug benefit
- scrutinizing unusual activities that might be considered fraudulent, as reported by the CMS, contractors, or Medicare beneficiaries
- conducting investigations about complaints of fraud
- referring cases to the appropriate law enforcement agency as needed
In addition to using MEDICs to investigate fraud, the CMS has recommended these precautions for Medicare beneficiaries to avoid scams:
- not giving personal information to PDP marketing representatives.
- adding their phone numbers to the Do Not Call registry.
- arranging for their Medicare Part D premiums to be deducted directly from their Social Security checks. By doing this, they do not have to write a personal bank account check, use a credit card, or reveal personal financial information to a third party, and they can easily keep track of their monthly premium payments.
- contacting the CMS by calling 1-800-Medicare if they suspect a problem.
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CONCLUSION
The strategies outlined in this article are meant to protect elderly patients against fraud and to help them make more informed decisions. Without question, health care professionals will play a major role in this process; otherwise, they will find it necessary to deal with procedural difficulties as the federal government works to improve the integrity of this complex program.
