Should I fill a prescription in my own name, intended for my mom?
May 9, 2015 8:17 PM   Subscribe

My mother is retired and disabled, on a fixed income. Every single year she hits the coverage gap (the "donut hole") on her medications, usually by September or October. This leads to the last three months of the year being a scramble of asking for free samples of her diabetic medications from her endocrinologist, and scraping to get by. At her last visit, her doctor straight-up offered to write the prescriptions in my name. My insurance would cover it with a simple copay and no coverage gap. Should I do this?

I guess my real question is, what are the potential consequences if this is discovered? And just how likely is it to be discovered? I am not diabetic, these are not medications I have ever taken myself.
posted by anonymous to Health & Fitness (35 answers total) 3 users marked this as a favorite
It's insurance fraud. It's probably felony insurance fraud. The doctor could lose his license and be prosecuted, if discovered.
posted by sonic meat machine at 8:21 PM on May 9, 2015 [17 favorites]

Barring the legal implications, your insurance will probably very likely need a qualifying diagnosis *for you* to go along with the scripts before they'll pay for them. So you might end up having a history of DM in your medical record, when you actually don't, which could cause all sorts of confusion among your providers down the line.
posted by un petit cadeau at 8:31 PM on May 9, 2015 [7 favorites]

Absolutely not. This is insurance fraud.
posted by asockpuppet at 8:32 PM on May 9, 2015 [4 favorites]

If the doctor is willing to go to those lengths why doesn't she just load up your mom with samples on her other visits? I have a really expensive medication that I haven't paid for in years because my doc always gives me samples. (His office manager even reminds me to bring a bag when he calls to confirm appointments.)
posted by Room 641-A at 8:35 PM on May 9, 2015 [7 favorites]

It's illegal. But I'd probably do it. The system is broken.
posted by BlahLaLa at 8:36 PM on May 9, 2015 [19 favorites]

Do NOT do this. Getting prosecuted for insurance fraud is only part of the problem. If Obamacare is ever repealed and we return to an insurance situation where pre-existing conditions are either not covered or covered much more expensively, your medical records will leave you so very, very stuck.

As a diabetic, I can tell you that most of the pharma companies have programs for deep discounts on meds, whether you have insurance or not. If she's on metformin, she should already be getting that for no more than $4/month. If she's taking oral meds for which there's no generic (like Januvia/Janumet), scour the web site for the pharma company that makes the meds and you should find discount programs. The same for goes for insulin, especially if he's got her on something more expensive (like Apidra) that the insurance companies don't want to cover. (In many cases, the doctor can write a prescription for double the dosage; if the pill can be split, then she'll get twice the meds for same cost.)

Also, she can request samples through the year and not wait until September. If she's seeing him every 3 or 4 months and gets a month of samples at each visit, it will be easier to accomplish.

Similarly, she can get discounted glucose test strips. The back cover of the newest issue of Diabetes Self-Management has an add for Accu-Chek's discounted test strip "preferred savings" program, which works whether or not you have insurance. Flip through this magazine and Diabetes Forecast to check out ads explaining all of these discount programs.

Finally, even if she doesn't get ANY of these discount programs (and she really should be able to), there are other pharmacy discount plans that can be used during the donut hole. If you have AAA (auto club), for example, you get a free prescription discount card. It's only about 10%, but it's something to look at that's less dire than breaking the law and risking your ability to get medical coverage for the rest of your life.
posted by The Wrong Kind of Cheese at 8:43 PM on May 9, 2015 [38 favorites]

If you Google a drug name and "prescription assistance" you can often find programs through the drug manufacturers for helping with the costs.
posted by XMLicious at 8:44 PM on May 9, 2015 [1 favorite]

Manufacturer coupons are ineligible for use with Medicare Part D.
posted by asockpuppet at 8:50 PM on May 9, 2015 [2 favorites]

No. Legal issues aside, remember that pharmacies keep track of drug interactions. What happens if you have a condition requiring a drug that has an adverse interaction with your mom's diabetic medicine?

The pharmacist may very well withhold your prescription until all liability issues are dealt with, or refuse outright to dispense it. If you are ever in serious pain or discomfort, that is the last thing that you want.

Even if you take it to a different pharmacy, keep in mind that most pharmacies subscribe to prescription drug monitoring program, so they know what prescriptions you're filling and where.

(Note: the NAMSDL website is rather clunky- the above page has a menu which will only appear if you expand it.)
posted by invisible ink at 9:17 PM on May 9, 2015 [1 favorite]

For supplies, as opposed to meds, then eBay is a safer last-recourse option, even though the sellers are probably Medicare recipients being overprescribed test strips (or perhaps people who go around assisted-living communities in Florida buying them off seniors). Load up on samples during the year, as the reps will always bring more pharmaceutical candy. If there's a local diabetes support group, seek them out, because part of that support is potlucks, if you get my drift.

Don't do it, for the reasons stated above, even though stuff like this happens all the time, whether it's writing prescriptions in other people's names, or a friend/family doctor who writes a prescription to save someone the cost of an office visit. Yay America.
posted by holgate at 9:17 PM on May 9, 2015

It's fraudulent behavior, and while I understand the motivation, I think maybe we random internet strangers have no idea how risky it really is. I wouldn't be so sure about the "needle in a haystack" defense. I'm a professional computer programmer and searching through a haystack of medical/insurance records looking for red flags is precisely the kind of thing that computers are pretty good at, and getting better. I'd be very surprised if insurance companies were not already employing IT approaches to rooting out fraud.
posted by axiom at 9:18 PM on May 9, 2015 [6 favorites]

I wouldn't recommend doing this. It is insurance fraud. I would also question the ethics of a doctor who actively encouraged insurance fraud, encouraging you to become a criminal, and look for a different doctor.

The good news is that Obamacare is gradually eliminating the doughnut hole. For 2015, you only pay 45% of the cost of medications while in the doughnut hole instead of 100% pre-Obamacare.

Even better, while you only pay 45%, the full 100% cost accrues to your out-of-pocket limit so that you reach the top of the doughnut hole faster. What this means is that in 2015, you will pay a maximum of $783 out of pocket while in the doughnut hole. Rather than participating in insurance fraud, it would be better if you and your mother could come up with the approximately $65 per month to cover the doughnut hole.

Each year the portion you pay will decrease until the doughnut hole is entirely eliminated.
posted by JackFlash at 9:46 PM on May 9, 2015 [6 favorites]

Check the GoodRx website to see what their discount is for the meds your mom needs. When my SO was temporarily uninsured last year it cut the cost of her medications by well over half.
posted by wierdo at 9:58 PM on May 9, 2015 [1 favorite]

The doctor probably has more on the line than you do (writing scripts for people who you don't have a therapeutic relationship with is considered very risky liability-wise, in addition to the fraud issue), and s/he's doing it in the name of helping her patient (your mom) stay healthy, so I actually think this is an offer made out of kindness and definitely wouldn't consider switching docs over it. It can be really hard as a doc watching patients struggle to afford their medications while pharmaceutical companies and insurance companies rake in the dough. That said, of course you should go the legal route.

Is she already getting generics whenever possible? Do any of the medications have cheap but very similar alternatives? Have her discuss this with the doc, if she hasn't already.

As I said, I wouldn't encourage you to do anything illegal, and I don't doubt there might be some way to get busted while doing this (even though I'm not familiar with it happening or how it would happen - and I'm an MD), but some of the issues listed above aren't really very big concerns.

For example, insurance companies look at your actual medical records for pre-existing conditions, and your medical records (kept at your doctor's office) are not going to reflect you taking these medications. Since we don't have a national health network or national electronic health record, there's really no way to track what prescriptions people are filling, aside from the new state controlled substances monitoring programs - which are for doctors and not insurance companies, as far as I am aware. Also, if a pharmacist in the future said there was an interaction between a medication you were trying to fill and your mom's diabetes medication, you could just say you're not taking that medication anymore, and then fill the two scripts at different pharmacies. Again, because there is no national system for tracking people's medical records or prescriptions, if you go to Walgreens they have no idea what you just filled at CVS or Mom and Pop's Local Pharmacy. Just pointing that out for a theoretical situation in which someone might decide to try to commit insurance fraud, even though strangers on the internet encouraged them not to.
posted by treehorn+bunny at 10:10 PM on May 9, 2015 [12 favorites]

Also, to be very clear, the prescription drug monitoring programs mentioned above are for controlled substances, not for all medications.
posted by treehorn+bunny at 10:13 PM on May 9, 2015

I'm not sure if this will work with medications for diabetes, but I do know some people get prescriptions for double the amount of pills they actually take, so that they can get 60 days out of one prescription rather than 30 days. Like, if she needs to take a pill twice a day, maybe he can instruct her to take two pills twice a day. Or something. I know that this may not work if you're dealing with insulin, but it seems like her doctor really wants to help her out with this, so this may be something to discuss.

I mean, I'm sure this kind of thing is frowned upon as well, but it seems much less likely to cause problems then what you're proposing here.
posted by litera scripta manet at 10:29 PM on May 9, 2015 [1 favorite]

Your doctor probably understands the consequences better than anyone here. If I had to break the rules to get my mother the drugs she needs, I'd break the rules.

Ethics is not identical with rule observance.
posted by Segundus at 10:34 PM on May 9, 2015 [12 favorites]

Like, if she needs to take a pill twice a day, maybe he can instruct her to take two pills twice a day.

I write software for a system that does electronic prescriptions, and if that double dose falls outside the normal range the pharmacy is likely to ask a lot of questions before filling it.
posted by DreamerFi at 2:35 AM on May 10, 2015

As others have said, no.

You can, however, pay for her prescriptions directly. You could provide her pharmacy with credit card details and then they'd charge you. Since the pharmacy is still dispensing the drugs to her, they will count as purchases to take her through the donut hole.

Most pharmacies offer a modest discount and only one co-pay for a 3-month supply, which could lower costs.
posted by Jesse the K at 4:19 AM on May 10, 2015 [2 favorites]

You and your mom may benefit from the counseling help of the Medicare Rights Center. They're a nonprofit advocacy group working on behalf of Medicare beneficiaries. They - through a hotline - help people on Medicare figure out what options are best for them each year (if your plan isn't working, maybe there is one that does), appeal coverage denials and inform Medicare and congress about what is and isn't working.
posted by mjb at 4:53 AM on May 10, 2015

For example, insurance companies look at your actual medical records for pre-existing conditions, and your medical records (kept at your doctor's office) are not going to reflect you taking these medications.

Sometimes, they do. Both written and electronic prescription copies can end up in a file. Do not underestimate how closely yours is being monitored by your insurance company. If they see anything odd - like a prescription being written for a condition otherwise not mentioned in tests or other records - they will investigate. If they're so inclined, they'll schedule you for an evaluation with another doctor, and it'll become readily apparent that you don't actually need those meds. You'd immediately lose your coverage, among other things.

As much as I really feel for you guys as someone who currently lacks coverage, do not fuck with your insurance company.

Source: my firm works with insurance companies. I have handled cases where an insurance company suspected fraud. It's not pretty, and being sued for fraud is nasty business.
posted by Ashen at 5:24 AM on May 10, 2015

I'm rather shocked that your mom's doctor jumped right to insurance fraud as a solution to the cost of her prescriptions. There are better, perfectly legal options, and I'm surprised the doctor didn't suggest them:

- If the doctor's office is connected to a hospital or medical group, there should be a social worker somewhere on the premises. Most hospitals have them; your mom is not the only person who has trouble paying for medical care. Ask to talk to a social worker, medical advocate, ombudsperson, or whatever name this person goes by, and explain your mom's situation. The social worker should be able to help you come to a legal solution.

- If the doctor's office has no social worker/caseworker: Google "department of aging" for your area (some are city-based, some are county-based). When you find the local department of aging (sometimes it's called Aging and Disability Services, or Adult Services), give them a call and explain the situation. They can help your mom access financial help or free samples of her medications, and perhaps there are other services for low-income senior citizens that she might not be aware of.

- It should be easy to pay for her prescriptions yourself, as Jesse the K said. Just put your credit card on file at the pharmacy so it gets charged for your mom's meds. That is perfectly legal and the pharmacy won't bat an eye - as long as they have your permission to use the credit card, they don't give a hoot who pays for mom's meds.
posted by Rosie M. Banks at 5:42 AM on May 10, 2015 [1 favorite]

I'm sure OP realizes that s/he could pay for the meds on a credit card, but that would cost way more than the copay s/he would pay if the prescription were made out to OP. I agree, though, that it's a bad idea. It is insurance fraud. If you have insurance through your employer, you're defrauding your employer too. Maybe they'd be sympathetic, maybe not.
posted by mskyle at 5:50 AM on May 10, 2015

When I googled "Senior Prescription Assistance" I came up with these:

Medicare Pharmaceutical Asisstance Program

State Pharmaceutical Assistance Programs

You would probably get some additional results if you googled "Senior Prescription Drug Assistance [YourState]" as they appear to be state-based; when I googled "senior prescription assistance [MyCounty]" I came up with a couple of county-based programs as well. Try searching for prescription assistance programs by your specific state and then county.
posted by Rosie M. Banks at 6:22 AM on May 10, 2015

I agree that all these nice links to help-the-poor schemes should be pursued. But my experience with such schemes is that one spends several days on the telephone to hear: that program is out of funding for this calendar year (totally possible in May, I promise); that particular thing is not a thing we deal with despite (a doctor, our web site, etc) leading you to believe otherwise; of course we can help! we will cover 30% of the cost after you spend three weeks gathering an inch of paperwork; etc, etc, etc. If there were magical places that consistently did that sort of thing and did them well, OP would never have ended up asking this question. Which was:

I guess my real question is, what are the potential consequences if this is discovered?

and there isn't much of an answer...

I would also consider looking at grey if not outright black markets and see if the drugs can be sourced cheaply there. Can it be bought for pets, for example? Do any of the prescriptions have a very modest recreational appeal, are they going to be for sale at a discount on "darknet" markets? Have you cast about on your social networks to see if anybody has leftovers of the same drugs? Can they be bought from sketchy on-line pharmacies overseas? I know, I know, we're sure these things are all cut with anthrax, etc, but the most damning indictment I have ever read is that sometimes the cheap foreign whatever does not contain as much of the drug as indicated.
posted by kmennie at 7:35 AM on May 10, 2015 [1 favorite]

I can't believe that people are suggesting that black market drugs are better than a little insurance fraud. Black market drugs could kill the old lady.

You may be stuck this year, but going forward work with your Mom's Dr. to get as many samples as possible AND schedule prescriptions so that a 90 day supply is on hand at the time the donut hole kicks in.
posted by Gungho at 7:55 AM on May 10, 2015

schedule prescriptions so that a 90 day supply is on hand at the time the donut hole kicks in.

That's not the way the doughnut hole works. It is a fixed dollar spending limit and as soon as you pass that threshold, you pay begin paying, even if it is in the middle of a 90-day prescription payment.
posted by JackFlash at 8:04 AM on May 10, 2015

your medical records (kept at your doctor's office) are not going to reflect you taking these medications. Since we don't have a national health network or national electronic health record, there's really no way to track what prescriptions people are filling,

This is wrong. I work in population health analytics and data management for a large mutli-specialty physician group. I'm the central point for data exchange between our organization and insurance companies.

The primary source of information that insurance companies have about your care is the claims you file. This absolutely includes medication claims. Insurers use that information in a lot of ways - for example, to identify patients who could benefit from case management. Filling a diabetic medication could absolutely be a trigger for your insurance to review your information for participation in some sort of diabetes management plan. This is more closely monitored in the Medicare population, but we routinely get lists of patients that have evidence of a condition, but who have not been diagnosed with that condition. The goal isn't even to prevent fraud, but to optimize diagnostic coding by physicians.

If your physician's office subscribes to SureScripts, then they get information about your medication fill history, regardless of who wrote the prescription or where you filled it.

Your risk of this being caught varies in a couple of different ways. First, the Medicare population is being much more closely monitored in this way than people who are in regular commercial insurance. If either your mother's doctor of your doctor are in groups that are participating in accountable care organizations or newer care and reimbursement models, then the risk of discovery goes up. If your commercial insurance is a "narrow network" or closely monitored (i.e., it seems like your company is really sensitive to the cost of insurance and has made changes to restrict access and decrease costs), your risk of getting caught goes up.

Most physicians are completely unaware of which data is going where and who is looking at it for what reason.

I would encourage you not to do this, and look into some of the other resources described above. This doctor may have her heart in the right place, but her approach here would give me a lot of concern.
posted by jeoc at 8:24 AM on May 10, 2015 [8 favorites]

Keep the meds in mom's name. That way, the co-pay still applies, and counts toward the donut hole, and everyone stays out of jail. You simply pay for them out of your own pocket when you pick them up at the pharmacy.
posted by Thorzdad at 9:04 AM on May 10, 2015

If the OP had said something like, "My mom can't afford to pay for her meds. I can't afford to help her pay for them, and neither can anyone else. I've exhausted every free or low-cost resource I can find, and so has my doctor. In desperation, my doctor suggested prescribing the meds to me as a last-ditch effort. What would be the consequences?" then I would assume that OP has tried and tapped out all the known legal ways to get Mom her medicines. (I'd still suggest contacting a social worker, elder-law specialist lawyer, or other professional, though.)

No matter what, I think insurance fraud is a terrible idea, especially when it comes to Medicare, which is being scrutinized much more carefully these days. I hope OP can find a legal avenue to get Mom her meds.
posted by Rosie M. Banks at 9:52 AM on May 10, 2015

Having worked at a medical insurance company, I can assure you that they take insurance fraud very, very seriously. They look for it, they research potential cases, they profile, they prosecute. Committing insurance fraud is not a risk I would want to take -- having a felony on your record would limit your future work options (not to mention jail time and hefty fines).
posted by LittleMy at 11:29 AM on May 10, 2015

What this means is that in 2015, you will pay a maximum of $783 out of pocket while in the doughnut hole.

I'd investigate putting this on some 0% for a year/really low rate credit card and just paying it off as you can. Is this not an option?

My first thought and step here would be "how do i come up with $800", not "how do i get away with doing fucky insurance things/should i do that".

So you have 4+ months to come up with $800. Less than $800 actually. That's under $200 a month, or some alternate way like a credit card to throw it all on. Is that not possible?

I make less money than a lot of people on mefi, and i'd consider that a solvable problem. Or at the very least, a problem i could very likely solve.

I really thought this was going to be over some super expensive $7000 or even $25000 a month type medication. I would seriously consider, personally, doing something like this if that were the case. But $800? That's just not, in the vast majority of cases, a do something super sketchy amount of money.
posted by emptythought at 1:01 PM on May 10, 2015 [3 favorites]

Like, if i craigslisted my smartphone, TV, and laptop then bought the absolute most basic barebones versions of those 3 things used to tide me over for a while i would probably have that money. I would dump a bunch of my stuff off on the used market via craigslist/ebay/etc to achieve this goal before i would go the insurance fraud route.
posted by emptythought at 5:02 PM on May 10, 2015

Agreeing with several commenters who have said in several ways, plan better for next year. Get a plan with no donut whole, or of that is too expensive, save up the money during the year for the expensive months.

As for this year, don't commit fraud. Do cover some of the cost for her.
posted by SemiSalt at 6:04 PM on May 10, 2015

Sign her up on Mechanical Turk. She can complete surveys and identify objects in photographs. By autumn she could have $800.

The doctor's suggestion is ill advised, with consequences that could avalanche in your life for decades.
posted by ohshenandoah at 2:05 PM on May 11, 2015

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