For Professionals: Medicare fraud and abuse

MEDIC Is Here to Monitor Part D Fraud

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Published: June 2006

Whenever a new program begins under Medicare the potential for fraud and abuse is extremely high. The beginning of Medicare Part D is no exception. To prevent and address this threat, the Centers for Medicare and Medicaid Services (CMS) has hired Delmarva Foundation as a Medicare Integrity Drug Contractor (MEDIC) to monitor Part D fraud, waste and abuse. The work is performed through Health Integrity, LLC, a wholly owned subsidiary.

In monitoring the new prescription drug program, Delmarva investigates many beneficiary complaints related to Part D. Examples of these types of complaints may include:

  • An individual or organization pretended to represent Medicare and/or Social Security, and asked a beneficiary for her/his Medicare or Social Security number, bank account number, credit card number, money, etc.
  • Someone asked a beneficiary to sell his/her Medicare prescription drug card.
  • Someone asked a beneficiary to get drugs for them using her/his Medicare prescription drug card.
  • A Medicare prescription Drug Plan discriminated against a beneficiary, including not letting him/her sign up for their plan because of his/her age, health, race, religion, income.
  • A beneficiary was encouraged to disenroll from his/her plan.
  • A beneficiary was offered cash to sign up for a Medicare prescription drug plan.
  • A beneficiary was offered a gift worth more than $15 to sign up for a Medicare prescription drug plan.
  • A pharmacy did not give a beneficiary all of their drugs.
  • A beneficiary was billed for drugs that s/he didn’t receive.
  • A beneficiary was charged more than once for their premium costs.
  • A Medicare prescription drug plan did not pay for a beneficiary’s covered drugs.
  • A beneficiary received a different drug than the doctor ordered.

Delmarva also handles marketing misconduct complaints regarding Part D plan agents. Beneficiaries and advocates wanting to report such complaints can either contact MEDIC by phone at (877) 7SafeRx – (877) 772-3379, or fax them at (410) 819-8698. Their website (www.healthintegrity.org) also has detailed information on case referrals and the MEDIC in general. To follow up on a case already submitted, call (866) 886-2658.

The California Senior Medicare Patrol (SMP) has referred four cases to the MEDIC since its inception. Three of the cases have remained open, and one case opened and closed within 60 days. Throughout the process of the latter case, SMP has been impressed with MEDIC’s communication and expedience. California Health Advocates’ SMP Director and Project Coordinator, Julie Schoen and Anne Gray also serve on the MEDIC Consumer Protection Panel which convenes monthly to discuss current problems/solutions. It is made up of several members, including six SMP programs, AARP, the American Society of Consultant Pharmacies, the California Department on Aging, the National Association of Attorneys General, the National Caucus and Center on Black Aged, the National Citizens’ Coalition for Nursing Home Reform, and several CMS Regional Offices and Health Integrity members.

Beneficiaries and advocates may also report their Part D questions and concerns directly to California Health Advocates' SMP office. They will then will open a case and file it to the MEDIC. For further information, contact Julie Schoen or Anne Gray at (714) 560-0309; full contact info here.

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