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THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM

MARCH 2002 NICA NEWS

ISSUES

Medicare Fraud and Abuse Detection Efforts
by Paula Haisch, Region VII MFIS

Health care fraud, waste and abuse costs the nation approximately 10% of the money spent on health care annually, costing taxpayers more than $25 billion. So what is being done about it and what is an MFIS?

MFIS is an acronym the Centers for Medicare & Medicaid Services (CMS) uses for a position of national importance to our Medicare system. We're talking about a Medicare Fraud Information Specialist (MFIS). There are eighteen such positions nationwide. These specialists have worked to form a network of Medicare contractors, law enforcement agencies, beneficiary organizations, state

Medicare/Medicaid coalitions, and provider groups, while serving as a liaison with their respective CMS Regional Offices.

The spectrum of their work includes the distribution of fraud related information to and from Medicare contractors and law enforcement entities. This is achieved through individual statewide fraud taskforces and a system of fraud alerts disseminated by the MFIS network. Because of this valuable network, Medicare contractors and law enforcement agencies can quickly be made aware of potential problem areas, for example a fraud scheme in Florida, or a deliberate improper billing practice in the New York region may be more quickly detected in Arizona because of this sharing of information.

Another equally important responsibility of the MFIS network is to provide fraud related training upon request to Medicare contractors, state Medicaid fraud offices, to the Department of Health and Human Services, law enforcement agencies, and to provider groups. The MFIS network also focuses their fraud training outreach on Medicare beneficiaries. Beneficiaries play a vital role in the detection of Medicare fraud and/or abusive billing practices. This has been clearly demonstrated by the Senior Patrol Project grants, formally known as Harkin grants, introduced by Senator Tom Harkin of Iowa several years ago. Administered by the Administration on Aging, these grantee programs work at the grass roots level to educate seniors about fraud and abuse in the Medicare program. On a national scale, the MFIS network works with these projects and other beneficiary advocacy organizations to help volunteers identify abuses of fraud and waste in our Medicare system.

It is through the MFIS network and it's processes that another initiative to protect the Social Security Fund is at work. Fraud education and outreach, and the dissemination of fraud information woven through a national network are what constitute the role of the MFIS. If you suspect health care fraud or abuse related to the Medicare program, you can contact Paula Haisch at 913-385-4200.

An Enlightening Explanation to Spring Fever

If you find your mind wandering as the weather warms, you can blame it on your physiology. Long-recognized by artists and poets as spring fever, now scientists say it is a physiological reality.

Spring fever's symptoms start popping during the onset of the vernal equinox. In the northern hemisphere, people begin to feel more energetic, enthusiastic, and amorous. At the same time, they also begin to feel listless and restless. It's easier to lose weight, and lots of folks walk around, randomly smiling at strangers.

The culprit of such behavior is the chemical changes that take place in the body in part because of increased exposure to daylight. Like other animals, we humans are strongly connected physically to the seasons. Scientists cite a number of factors that cause spring fever:

Increased light sends signals to the brain's pineal gland, which then reduces its production of melatonin, a hormone that regulates our body clock and controls our mood and energy levels. As the days grow longer, the chemical disappears and leaves people feeling more energized and confident.
Increased light also transmits to the hypothalamus, the section of the brain that regulates eating, sleeping and sex drive.
Our other senses-sight, smell, and hearing-also wake up as blossoms and spring breezes assault them. Such stimuli can trigger strong emotions, from euphoria to sadness.

(Adapted from the Chicago Tribune)

NeedyMeds.com

Another option for people who need help with prescriptions is now on the internet. NeedyMeds is NOT a drug assistance program, but is an information provider. NeedyMeds makes information available to you so you will know how to get help from patient assistance programs. These programs are provided by many different pharmaceutical manufacturers.

The website has a list of all the drugs currently in the NeedyMeds system. From there you can go directly to the page that has the information about the drug you are interested in. The site also lists all the pharmaceutical manufacturers in the NeedyMeds system.

Patients who need help paying for medications are invited to use the NeedyMeds site as often as they like to get the information they need about the pharma-ceutical manufacturer's programs. The NeedyMeds website is free.

They suggest that you print out the pages for the programs that cover the medications you are taking. The next step would be for you to either obtain an application for those programs if the pages say that you can call the company yourself or ask your doctor's office or social worker to call the company for you. Having the information will give you more knowledge about the process and allow you to be prepared for your role in the process. If the page you print tells you that you will need to provide extensive financial information and documentation, then you should be prepared to fill out that part of the form and enclose the required documentation.

There is no charge for using this information.

Discounted Drugs to Low-Income Seniors

Pfizer (pharmaceutical manufacturer of such drugs as Lipitor and Viagra) is offering a discount to senior citizens on their most widely used prescription drugs beginning March 1. This discount will allow low-income seniors to purchase their prescrip-tion drugs for only $15 a month. To qualify for this discount, patients must be enrolled in Medicare and have an annual income of $18,000 or less for individuals and $24,000 for couples, and they cannot have any other type of prescription drug coverage. There are no limits on amount of prescriptions and no enrollment fee. For more information call Pfizer at 1-800-717-6005.

The Pfizer Share Card is not a Medicare-approved prescription drug discount card and there is no Medicare prescription drug discount card program currently available.

Novartis CareCard
Novartis Pharma-ceuticals CareCard is designed to make prescriptions more affordable for low-income elderly Americans who lack drug coverage. For more information on this new discount drug card visit the website www.pharma.us.novartis.com/carecard/2card2.shtml or call 1-800-974-CARE (2273)

More Medicare Prescription Drug Benefit Proposals. On January 28 President Bush offered several new prescription drug benefit proposals. The President would spend $190 billion over 10 years to offer prescription drug coverage to low-income seniors. One part of the plan offers states $77 billion to pay for 90% of the costs of providing prescription drug coverage to low-income beneficiaries with annual incomes between 100% and 150% of the federal poverty level.

The other part of the plan, known as Pharmacy Plus, allows 18 states to create demonstration programs under Medicaid waiver authority to provide drug coverage for seniors whose income is below 200% of the federal poverty level. The U.S. Department of Health and Human Services just approved a similar Illinois Medicaid waiver to expand the number of prescriptions available to low-income seniors.

A third proposal is to offer two new Medigap plans that would provide payment for prescription drugs for low-income seniors. The President also intends to move ahead on the proposed prescription drug discount card that he had proposed in 2001. For more information, see: www.kaisernetwork.org/dailyreports/healthpolicy.

Severe Overcrowding of America's ER's
There is growing concern about the crowded conditions in hospital emergency departments across the country. Increasingly, hospital emergency rooms are forced to send patients to other hospitals. Surveys show that ER visits rose from 90 million in 1994 to nearly 100 million in 1999, including a 5% rise between 1998 and 1999 alone, while the number of available beds has dropped from 820,000 to 745,000 over the same period. Some proposed reasons for this overcrowding include greater demands of aging baby boomers, as well as reductions in hospital services due to budget cuts from the Balanced Budget Act of 1997.