Still, we are aware that there are other versions of fraud out there. This week a really sad case came through the electronic grapevine from the listserve for the National Association of Drug Diversion Investigators. In a message that originated from Special Agent Rick Zenuch (Florida Department of Law Enforcement, Office of Statewide Intelligence) comes the story of a Medicare boondoggle that is bad enough in itself but which also involved paying clients with HIV to submit to treatments that included diluted or counterfeit medications.
Here’s what Special Agent Zenuch had to say:
I wanted to share with you a problem we are working on in the Miami area that while it is more appropriately classified as healthcare fraud, may come to the attention of diversion investigators. The bulk of the problem is predominantly in Miami-Dade county but the practice is not necessarily limited to this area. Here is an excerpt from a brief I recently wrote:Special Agent Zenuch goes on to explain how the Medicare billing system allows for such fraud and ongoing efforts to correct the problem. He also talks about law enforcement activities from state and federal agencies to further address the problem.
"The fraud involves medical clinics billing the Medicare/Medicaid system for drug infusion treatments that are administered to HIV/AIDS patients. One of the treatments for HIV/AIDS patients involves the intravenous administration of different drugs designed to fight the disease and boost the immune system. Some of these drugs are extremely expensive and can range between an estimated $2000-$8000 a treatment. These treatments are usually billed to Medicare because once a person is diagnosed with HID/AIDS (sic), they become classified as disabled by the Social Security Administration and become eligible for Medicare benefits. Many of these patients are also indigent, qualifying them for Medicaid benefits as well.
Data from Jan-May of 2005 shows that Florida's average submitted charge for these IV type treatments, per beneficiary, is four times higher than California and ten times higher than New York. Florida, with fewer AIDS cases than California and New York, (94,725 to 133,292 and 162,466 respectively) has submitted total charges for these billing codes to the Medicare/Medicaid system in excess of 1.5 billion dollars, three times California and 5 times the New York charges.
What has emerged in Miami, where the largest percentage of this billable procedure takes place in Florida, is a systematic fraud by health care clinics and practitioners whereby patients are recruited for treatments and either infused with placebos, adulterated (diluted) drugs or simply not treated at all, while the practitioner/clinic bills the system for full payment. The patient receives a "fee" for participating in the scheme, usually from $100-$400.