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    lindalogsdon's Avatar
    lindalogsdon Posts: 1, Reputation: 1
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    #1

    Aug 22, 2012, 08:03 AM
    Prescription insurance fraud
    If a resident in a long term care facility has a medication reordered through the nurses at the facility and his Med D insurance plan denies the refill electronically as a refill too soon to the long term care pharmacy... is it breaking a law or committing insurance fraud if the med is sent out today and is not payable till tomorrow or the next and the dispense date is changed to the date the insurance will pay the claim? Essentially, the long term care pharmacy is sending the med out "no charge" until a day or two later when it would be payable by the plan. Of course, billing for a med today and then NOT dispensing it until tomorrow definitely falls into the fraud category. Medicare D insurance has a narrow window of when a claim is payable which in the LTC setting, can make the drug supply at the facility run too short. If a patient spits a pill out or one is dropped, the med may have to be dispensed a day or two before the insurance says it is payable again.
    Fr_Chuck's Avatar
    Fr_Chuck Posts: 81,272, Reputation: 7690
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    #2

    Aug 22, 2012, 08:16 AM
    No it is not fraud, but the medicare may not pay for it, and the patient could be liable to pay the full cost of medicare refuses it.

    It is the drug company that is actually breaking the law, sending it out without proper authorization of payment, they are they ones who will bill as it is shipped out latter, so they are lying when they submit for payment.

    The patient has no issue here.

    *** this is a common practice, a lot of medical equipment is given out, or shipped prior to approval. Most equipment like wheel chairs, electric wheel chairs, canes and more are all done the same way, the patent gets them, they wait for approval and then bill like they just gave them to the patient,

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