Senior News
July 2009, Volume 12, Number 2
The False Claim Act is a federal statute which prohibits the defrauding of federally funded programs. Under the False Claim Act severe civil penalties are given to anybody who commits Medicaid fraud. Any person who makes a false claim to Medicaid is liable under the Act for up to $11,000 in fines plus three times the amount of damages sustained by the Medicaid program.
To be liable under the Act, it is not necessary that the person intentionally defraud the Medicaid program. Rather, health care providers can be prosecuted for any conduct which leads to the submission of fraudulent claims. Such conduct includes double-billing, falsifying records, making false statements and submitting bills for services never performed.
Until recently, the government had a difficult time enforcing the False Claim Act. In 2006, however, the Deficit Reduction Act (DRA) was passed, which created the Medicaid Integrity Program (MIP). The MIP is specifically designed to fight back against Medicaid provider fraud, waste, and abuse. Under the MIP, contractors are hired to educate Medicaid providers and perform reviews and audits to ensure that health care providers follow Medicaid rules.
Section 6032 of the DRA goes further to prevent Medicaid fraud. It requires all health care providers accepting Medicaid payments of $5 million or more per year to implement educational policies to combat fraud. Under this section of the DRA, such policies must explain the False Claims Act and be made available to all employees, agents, and contractors. These policies must also include detailed information on whistleblower protection laws so that employees feel secure in helping to detect and prevent fraud, waste, and abuse.
Even providers not required to create written compliance policies under Section 6032 of the DRA must abide by the False Claims Act. Because of this, many organizations opt to implement written compliance policies despite falling short of the $5 million threshold. Whether or not it is required by Section 6032 of the DRA, health care providers stand to benefit from implementing policies against Medicaid fraud and abuse.
Double-Dipping
One of the most prevalent types of Medicaid fraud committed by health care providers is referred to as “double-dipping.” This is when providers who accept ALTCS members charge them for services already covered by ALTCS. Even health care providers who are dissatisfied with the ALTCS reimbursement rate cannot charge additional fees to ALTCS members for services already covered by ALTCS. Any time health care providers receive payment from ALTCS and a member for the same service they are double-dipping.
Health care providers are permitted to charge ALTCS members for services not covered under the member’s contract. For instance, health care providers can charge members for services such as room upgrades not covered by ALTCS. However, providers are not allowed to require members to make additional expenditures as a precondition to placement. If health care providers wish to charge more for their services they must make negotiations with the ALTCS program contractor and not the ALTCS member. Double-dipping is never permitted.
Double-dipping is just one example of Medicaid fraud. Any misuse of ALTCS dollars wastes valuable resources that should be spent on ALTCS members. ALTCS funds are finite and need to be allocated properly towards the welfare of ALTCS members.
For more information on DRA requirements and the False Claim Act please contact JacksonWhite Elder Law toll-free at 1-800-243-1160
The “Donut Hole” of Prescription Drug Coverage
Those who participate in the Medicare Part D prescription drug program sometimes run into trouble with a coverage gap referred to as “the donut hole”. This coverage gap falls between the initial coverage limit and the point where catastrophic coverage kicks in. If the cost of an individual’s prescription drugs falls anywhere in this donut hole, he or she is responsible to pay the entire amount. This can get quite expensive for Medicare recipients who do not participate in other needs-based programs.
While AHCCCS/ALTCS does not cover the cost of prescription medications, recipients who qualify for these benefits are considered dual eligible. These individuals are only responsible for co-pays of $1, $3, or $6 for prescription medications. Upon becoming dual eligible, an individual should immediately notify the Medicare Part D plan provider. Once Medicare is notified of the dual eligibility, the donut hole will go away. Coverage for medications that were once in the donut hole takes effect almost immediately after notifying the Medicare Part D plan provider of dual eligibility.
Upcoming ALTCS 101 Training Dates
New to Arizona? Need a refresher on ALTCS eligibility rules? Join us for an ALTCS 101.
Thursday, August 27th
JacksonWhite Mesa Office
40 North Center Street, Suite 200
Mesa, Arizona 85201
1- 3 p.m.
Thursday, September 3rd
Foundation for Senior Living, Caregiver House
1201 East Thomas Road
Phoenix, Arizona 85014
1:30 – 3:30 p.m.
Tuesday, October 13th
Immanuel Campus of Care
11301 N. 99th Avenue
Peoria, Arizona 85345
9 a.m. – 11 a.m.
Upcoming ALTCS 102 Training Dates
Already attended an ALTCS 101 but feel like there is still more to learn about ALTCS? ALTCS 102 picks up where the 101 training left off. If you’re an ALTCS 101 alumnus, register today!
Thursday, September 10th
JacksonWhite Mesa Office
40 North Center Street, Suite 200
Mesa, Arizona 85201
1 – 2:30 p.m.
Wednesday, September 16th
JacksonWhite Peoria Office
7972 W. Thunderbird Rd., Suite 105
Peoria, AZ 85381
2 – 3:30 p.m.
Seats for all ALTCS 101 and ALTCS 102 trainings are limited. Please RSVP to Julie Boyster at (480) 464-1111 or by email at jboyster@jacksonwhitelaw.com.
Parkinson’s Disease and Long-Term Care
JacksonWhite Elder Law and the Muhammad Ali Parkinson’s Center are pleased to announce the arrival of the new consumer guide Parkinson’s Disease and Long-Term Care.
Contact us at (480) 464-1111 or visit our Web site resource page to request a copy today!
Tags: ALTCS, Elder Law, Medicaid Fraud, Senior News
This is an outstanding look how seniors can stay aware of what health care providers might be doing to constitute Medicaid fraud. Home Instead Senior Care will keep an eye out for these kinds of situations. Thanks for the info!