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“Let the Crime Spree Begin”: How Fraudsters Benefit from Medicare’s Drug Plan

Denise Heap, whose mother lived in a nursing home, realized that either her mother was being given expensive medications for conditions she didn't have...or someone was using her mother to steal drugs.
 
 
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This article originally appeared on ProPublica, and is republished here with their permission.

At another time in her life, Denise Heap might have tossed aside the insurance forms listing the drugs prescribed to her mother.

The “explanation of benefits” forms came like clockwork and didn’t require any action on her part.

But Heap was worried about her mother, Joyce, who was in the end stages of Alzheimer’s disease. Her health had inexplicably declined in the Los Angeles-area nursing home where she’d been living. So in April, when a thick envelope arrived from her mother’s Medicare drug plan, Heap scrutinized it.

What she found was frightening: Her 77-year-old mother was receiving a raft of medications Heap had never seen before.

As Heap began Googling the drugs, she realized something was drastically wrong. Either her mother was being given expensive medications for conditions she didn't have — such as breast cancer, asthma, emphysema and high cholesterol — or something sinister was going on: Someone was using her mother to steal drugs.

“I flipped,” Heap said. Medicare's prescription program, known as Part D, paid for more than “$10,000 worth of meds” in just three months, she said.

She first called Medicare to report her suspicions, she said, then the insurance company that managed her mother’s Medicare drug plan. Neither, she said, seemed very concerned.

“I was like, ‘No. No. No. You have to understand. I am trying to help you guys,’” she said.

Soon, Heap became convinced someone had stolen her mother's identity while she was living at a nursing home run by an Armenian couple. The couple kept moving the location of the nursing home. And Heap believed they had been over-sedating her mother with high doses of antipsychotics, inappropriately treating her blood pressure and allowing bed bugs to feast on her.

“I knew something crooked was going on,” said Heap, 59, who, with her mother, had co-founded a Holocaust education nonprofit in the 1990s to document stories of German resistance to Hitler.

Frustrated, Heap called Los Angeles County sheriff's Sgt. Steve Opferman, head of a task force specializing in prescription drug fraud. As soon as Heap began describing what had happened, Opferman said he knew her mother had been caught up in a fraud scheme involving Armenian organized crime.

Opferman and other investigators say criminals wager that patients and their families will not be like Heap. They bank on the fact that their victims — Medicare beneficiaries — will be too old or too sick to review insurance forms summarizing the medications and services billed in their names. And they count on the tendency of busy family members to give such forms a cursory glance, if that.

“Suffice it to say most people don't pay attention, let alone know what they're looking at,” Opferman said.

But Heap's case, and others like it, shows the important role patients and their families can play in uncovering fraud within Part D. The program now covers 36 million seniors and disabled people and fills one in four prescriptions nationwide. Last year, it cost taxpayers $62 billion.

In an earlier report, ProPublica found that Medicare’s system for pursuing such fraud is so cumbersome and poorly run that schemes can quickly siphon away millions. Tips such as Heap's can come into private insurers, which run Part D for Medicare, to contractors hired by Medicare to spot fraud, or to the U.S. Department of Health Human Services inspector general, which investigates health care fraud. But only a small percentage of cases funneled through this chain are prosecuted.