Is this fraud?

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Specializes in Critical Care, Insurance Case Management.

I posted on the case management forum, but thought maybe someone here would know. If you know a sub acute rehab will not take a patient on an expensive chemo drug, is it fraud to have the patient fill the script on the way to rehab through a pharmacy, and treat it like a home med? Some of our inpt case managers think it is, but I can't see how it would be, and may be the only alternative if the patient needs placement and is being turned down due to expensive meds.

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Of course it's fraud. And dangerous. Neither I nor anyone with whom I work is qualified to hang chemo.

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Specializes in Critical Care, Insurance Case Management.

It is an oral med, not IV, and it is still prescribed by a Dr. So, I would like to know exactly WHY it is fraud.

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You are not disclosing the patient's true condition to the facility because you know that if you do he will not be accepted. You are getting him in under false pretenses. How is that NOT fraud?

Fraud Law Legal Definition

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Specializes in Critical Care, Insurance Case Management.

For the sake of further discussion, I assume the facility doesn't want the patient NOT because he needs the medication, but because they don't want to have the cost in their case mix. My assumption is that SARs have a set reimbursement based on diagnosis, and they avoid the costly patients. Of course the fact the patient has cancer would not be hidden, but if Medicare is billed for an outpatient med, doesn't this save the SAR from bearing it? This is not my case, and as an inpt planner, this is a serious issue if a patient needs rehab but we can't place them unless the Dr stops his medication. We often have pt's on chemo incidental to the reason for admission. I am reasonably new to inpt case management and finding ways to get folks on to the next level of care is full of barriers. Chemo shouldn't be one of them (it may just be palliative chemo) and sometimes they can't go straight home.

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The point is that you are getting the patient in fraudulently. You did not ask about the ethics of it but whether it is fraud. It is.

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Specializes in Critical Care, Insurance Case Management.

I appreciate your answers - there is always new twists and situations to learn in the world of medicine, insurance and money!

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Specializes in Geriatrics, Hospice, Palliative Care.

We've had several short term rehab patients bring their own supply of oral chemo meds...I didn't know that it might be a problem. Often, they are in for reconditioning after another unrelated event like a hip fx. My hat is off to you MDS nurses who have to understand all of this stuff, which often doesn't make a bit of sense towards getting patients the care that they need.

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Specializes in Long term care-geriatrics.

Unfortunately when a nursing home is deciding to take a patient, they are looking at the cost of and potential cost of that person's medications. So, to get that person placed, compromises have to be reached. If the family will agree to buy the medication, fine then the patient will find temporary placement and they will have the necessary therapy. Is this fraud? Medicare and Medicaid really don't care as long as they don't have to pay. It could be fraud if the patient leaves the hospital, uses their Medcaid and Medicare part D to buy the medicine and then go to the nursing home(the nursing home is suppose to buy the patients medications during those 100 Medicare days.)

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Specializes in Critical Care, Insurance Case Management.

I followed up on this today, and it turns out our onc case managers do this frequently and unless the chemo drug is a carve out and billed by rehab in spite of the patient already having it, it's not fraud. Besides, it's not us comitting fraud, it would be the rehab. So, my initial instincts were correct when I questioned the premise that it was fraud in the first place.

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Specializes in LTC, Hospice, Case Management.
It could be fraud if the patient leaves the hospital, uses their Medcaid and Medicare part D to buy the medicine and then go to the nursing home(the nursing home is suppose to buy the patients medications during those 100 Medicare days.)

This is my understanding as well. As a SNF provider, we have an obligation to provide all medications during their Medicare A skilled days.

If it was "Ok" to drop by the pharmacy & pick up Rx between hosp & SNF admits, soon SNF's would try to get all potential admits to do this for all of their medications...hey it would save us thousands of dollars!

Our average Rx cost for a medicare A resident is approx. $300-600/month. We avoid the "Mycofungin IV" meds which easily runs $15,000/mo

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Specializes in Long term care-geriatrics.

My question is who would you be commiting fraud on. The facility, Medicare, medicaid? Who?

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