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HIV drug fraud in Medicare plagues Miami.....& New York
  Brian Bandell
Senior Reporter- South Florida Business Journal
Aug 15, 2014
A federal report on potentially fraudulent Medicare claims for HIV drugs singled out Miami as the worst market by far.
Only 2 percent of Medicare beneficiaries who receive HIV drugs live in the Miami area, but it accounts for 24 percent of the people who had highly questionable billing patterns, according to a study by the Department of Health and Human Services' Office of Inspector General. The second highest area for questionable billing was New York with 14 percent, but that's more in proportion to the 10 percent of beneficiaries on HIV drugs that live there.
As part of its efforts to detect fraud, the OIG reviewed utilization patterns of HIV drug billings to Medicare in 2012. It found 1,600 beneficiaries with highly questionable utilization patterns who rang up $32 million in charges. Such patterns include receiving prescriptions for an unusually large amount of HIV drugs or receiving the drug from six or more pharmacies or physicians.
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The study found 888 beneficiaries who received HIV medications worth $6.5 million despite having no history of the disease on record.
"When Medicare pays for HIV drugs and there is no indication in the Medicare history that the beneficiary has HIV, it raises concerns about fraud and abuse," the OIG report said. "The beneficiary may have received the drugs and diverted them for sale on the black market. Another possibility is that the beneficiary never received the drugs. For example, the pharmacy could have submitted claims for drugs that were never dispensed, or the beneficiary's identification number could have been stolen."
Statistics show that Miami has a large population of young HIV-positive people, making it a ripe market to purchase HIV drugs from people on Medicare. The OIG report singled out two Miami pharmacies - without naming them - that submitted HIV drug bills for 321 beneficiaries who were not diagnosed with HIV. Most of these beneficiaries were women with an average age of 74, which is much older than the average Medicare beneficiary with HIV. These two pharmacies received $359,456 from Medicare for these drugs.
The OIG study found 179 beneficiaries who say at least six prescribers for HIV drugs in the single year, which raises concerns of "doctor shopping" to obtain an excessive amount of drugs. Forty-five percent of these beneficiaries were from Miami or New York.
In one extreme example provided by the OIG report, "A 48-year-old from Miami went to 28 pharmacies and had 16 prescribers for HIV drugs, which included 15 different types of drugs. The beneficiary received excessive doses and excessive supplies during the year. In total, Medicare paid $198,272 for HIV drugs for this beneficiary."
In other examples:
· A Florida beneficiary received 20 different HIV drugs from 32 prescribers and 20 pharmacies in 2012 with excessive supplies of the drugs. While on five different Part D plans, he caused $349,854 in Medicare billings for these drugs.
· A 37-year-old Miami beneficiary received 16 HIV drugs in one month and on some days he received drugs from two different pharmacies on the same day. Using nine physicians, he got Medicare to pay $146,160 for his drugs.
· Medicare paid $154,549 to supply HIV drugs to a 44-year-old beneficiary in Miami who saw 12 prescribers, 19 pharmacies and received more than three times the recommended doses of emtricitabine and tenofovir in a single year.
The OIG recommended that regulators intensify monitoring efforts linked to HIV drug usage Medicare claims, place more controls on specific beneficiaries, such as limiting their numbers of physicians and pharmacies, and follow up on questionable utilization patterns.

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