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Feb 5, 2014 by |

Potential Medicare Fraud and Abuse

For most Californians aged 65 and older, Medicare and Medicaid services are essential to their wellbeing, and many residents rely on these insurance and medical care providers for daily medications, routine doctor’s visits, and long-term care. But suspected problems within the federally-run programs could constitute abuse, elder abuse attorneys in San Francisco say.

Last month, the agency that runs the Medicare program announced that they would be sanctioning doctors who have prescribed drugs or unnecessary medications, in abuse of the system. According to the Centers for Medicare and Medicaid and Medicaid Services (CMS), the organization that will be overseeing the coming investigation, “abusive” prescriptions will not be determined by numerical quantities that should be restricted for certain medications, but by patient-doctor relationship, and the doctor’s choices in treatment. If CMS can determine that a physician’s actions “pose[d] a threat to the health or safety of seniors and the disabled,” they will consider these actions abusive, and discipline accordingly.

In their list of proposed changes, officials from CMS stated that they will remove doctors from Part D, the Medicare drug program, who have “repeatedly and consistently fail[ed] to exercise reasonable judgment in his or her prescribing practices.” Several cases of abusive practices made headlines last year, some detailing doctors who have prescribed large amounts of unneeded medications, or wasted the program’s money on expensive, unnecessary drugs. Taxpayers paid out over $60 billion in 2012 for Part D, and although many seniors rely on the program to received their medications, the acts of fraud that have been committed jeopardize the program’s availability to truly benefit older Californians, as well as their safety in being treated by program doctors. In one instance, a doctor had been caught prescribing antipsychotic drugs to elderly patients with dementia, even though a black-box warning advises doctors not to do so.

Based on the news of previous transgressions, CMS has come up with a list of 8 factors that they will use to determine whether or not abusive prescriptions have been ordered. Officials will be investigation whether the patient’s diagnosis necessitates the treatment or medication that the doctor prescribed, whether the doctor or provider could have actually seen a patient for whom they prescribed medication—i.e., if the patient was in the state, or alive, at the time of a billed and documented visit, or whether a certain provider had prescribed “excessive volumes” of painkillers or other popular drugs used in overdose scenarios. CMS will also be looking into physicians’ backgrounds, and flagging any previous disciplinary actions, or malpractice lawsuits, that Medicare or other welfare programs may have taken against providers.

Dr. Ardis Dee Hoven, the president of the American Medical Association, said that “responsible prescribing of pharmaceutical drugs is a fundamental aspect of medical practice and the [AMA] has zero tolerance for harming the health and safety of patients.” Anyone who prescribes inappropriate medication should be penalized, especially those who jeopardize elder patients’ safety by ignoring warnings or prescribing the wrong dosages for potentially threatening medications.

At the Evans Law Firm, our San Francisco elder abuse attorneys serve older Californians and their families in the SF Bay area. If you or your loved ones have been victims of abuse at the hands of a Medicare physician, contact the Evans Law Firm at 415-441-8669 or for a consultation.

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