Pharmacists and the $1.3 billion Medicare fraud case
Friday, July 21, 2017
On July 13, the federal government announced the largest takedown by the Medicare Fraud Strike Force in U.S. history. The agency charged 412 defendants — including doctors, nurses and pharmacists — with $1.3 billion in fraudulent billing schemes to Medicare, Medicaid and other private insurers. Groups of these defendants were spread across 41 federal districts.
The dollar amount seems staggering. According to the Strike Force (begun in 2007) website, the total dollars in fraud discovered as of May 31, 2017, was about $2.5 billion. The latest crackdown adds 50 percent to that total.
"Too many trusted medical professionals like doctors, nurses and pharmacists have chosen to violate their oaths and put greed ahead of their patients," said Attorney General Jeff Sessions, commenting on this discovery. "Amazingly, some have made their practices into multimillion dollar criminal enterprises. They seem oblivious to the disastrous consequences of their greed."
While the criminal activity — and yes, this is just as much a crime as robbing a bank — is inexcusable, it is also necessary to point out that the number of individuals involved in these schemes is still relatively small. But just a handful of these medical bandits can manage to generate billions of dollars in bogus claims.
The task is not unlike finding those proverbial needles in a haystack. But find them they have, and over the years they have "arrested more than a thousand criminals, and recovered millions of taxpayer dollars."
I want to alert new pharmacists to the potential for fraud in the workplace. These cases are warnings and red flags to us all. Understanding how fraud can happen should make you careful about how your respective businesses are run.
I have to believe that some pharmacists have unwittingly found themselves in organizations where fraud was occurring, but they might not have immediately recognized it. We understand the need to protect patients from medication errors, but we also need to protect the public (and our own licenses) from fraud.
What types of activity appears to have been going on in this latest $1.3 billion bust? A quick review of the reports highlights types of activity to watch out for.
1. Kickbacks. A kickback is any sort of financial (or other) incentive being used to help generate business that involves billing Medicare. You may not steer such patients with any form of compensation, nor may you solicit prescriptions or other medical orders in exchange for other goods or services. Among the cases currently being prosecuted was a group in the Southern District of Florida that recruited addicts to their treatment facility offering them "gift cards, free airline travel, trips to casinos and strip clubs, and drugs."
2. Fake claims. In some cases, claims or prescriptions were being billed for services that were never provided and drugs that were never dispensed. In the Central District of California, a fraud case was uncovered in which just two defendants conspired to bill Medicare and private insurances for $41.5 million in claims for "prescription drugs that were not filled by the pharmacy nor given to patients."
3. Compounded medications. Another target included several cases in which pharmacies billed for unnecessary compounded medicines. One case in southern Louisiana involved a pharmacist billing for $192 million in fraudulent claims to TRICARE for compounded prescriptions that "that were not medically necessary and often based on prescriptions induced by illegal kickback payments." Note, there is nothing inherently fraudulent about a compounded prescription order, but be aware that this category of medications may be subject to special scrutiny.
4. Opioids. Further perpetuating our national epidemic of narcotic abuse, many of the cases involved physicians selling opioid prescriptions to patients, often in conjunction with a pharmacy agreeing to dispense these drugs from such unscrupulous sources.
I'm glad the number of pharmacists involved in such activity is still an incredibly small percentage of our total profession. Nevertheless, we must all remain vigilant about the potential of such activity going on around us. Fraud can harm patients and ruin careers, and it is an attack on all the taxpayers of this country.
Sessions made it clear that the Task Force will continue to investigate all such fraudulent activity.
"While today is a historic day, the Department's work is not finished," he said. "In fact, it is just beginning. We will continue to find, arrest, prosecute, convict and incarcerate fraudsters and drug dealers wherever they are."
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