HIV and Medicare, Even if you Aren't HIV Positive

Should you have to pay for treatment for a condition you don't have? How about Medicare?

Would you expect Medicare to pay for treatment for a Medicare beneficiary if they are not sick?

Two years ago, the prescription drug program, known as Part D, shelled out $32 million for HIV drugs that could be traced to questionable use among almost 1,600 beneficiaries

In some cases, the report states, they had no indication of HIV in their Medicare histories; they received an excessive dose or supply of drugs; they received HIV medicines from a large number of pharmacies or prescribers; or they received drugs that should not be taken in combination with HIV medicines.

WSJ

Depending on your source, Medicare fraud is a $50 - $60 billion dollar industry. Most of the fraud could be preventable if the Medicare payment system wasn't so disjointed.

So why are we (the taxpayer) paying for HIV medication for people who are not HIV positive?

One beneficiary received $17,509 of HIV drugs in a single day and no other HIV drugs the rest of the year. On that same day, she received more than twice the recommended dose for five different HIV drug ingredients. But two of the drugs, Atripla and Complera, are complete drug regimens that do not need to be taken with other HIV drugs.

One beneficiary from New York received a 720-day supply of Norvir 100 mg. Almost every month in 2012, this beneficiary received this drug from two different pharmacies and two different prescribers. Recent research indicates that when ritonavir—the active ingredient in Norvir—is mixed with some illicit drugs, including ecstasy, it heightens the psychoactive effects of the drugs.

How much do these drugs cost?

Atripla - $2467 for 30 tablets, 30 day supply

Complera - $2468 for 30 tablets, 30 day supply

Norvir - $313 for 30 tablets, 30 day supply

That's a lot of jack.

in 2012, more than 135,500 beneficiaries received HIV drugs that were paid for by Medicare Part D

In case you are wondering, Medicare is not just for those age 65 and older. If you are under age 65 and qualify for SSDI (Social Security Disability Income) you can also receive Medicare benefits.

The backdrop to the report is ongoing concern that Medicare Part D has limited safeguards and so is vulnerable to fraud, waste, and abuse, an issue the OIG has raised before. But the program has placed few restrictions on beneficiaries, and those that do exist, for the most part, target prescription painkillers such as opioids.

At the same time, the OIG notes that a recent report found that 2,637 retail pharmacies had questionable billing in 2009. And another report found that 736 general-care physicians had questionable prescribing patterns. To the OIG, this all makes for a worrisome mix.

Here is the big problem.

Original Medicare (and supplement plans) along with Medicare Part D lack a prospective claim review system.

When a drug claim arrives at the PBM all they do is check to see if the Medicare beneficiary number is valid and the claim is submitted properly. Once that checks out the claim is paid.

Fraud is normally only discovered AFTER the claim is paid and the scoundrels have moved on.

The OIG suggests some obvious changes: the Centers for Medicare and Medicaid Services should expand its programs for reviewing and monitoring drug use and prescribing; restrict certain beneficiaries to a limited number of pharmacies or prescribers, and limit the ability of beneficiaries to switch plans, among other things.

Sounds good, but does not address the root cause of the problem.

Acccording to the WSJ article, the fraud in the referenced cases were caused by: