Becoming a Whistleblower, and exposing PBM & pharmacy fraud, helps ensure that precious healthcare resources are used as intended.
Becoming a Whistleblower, and exposing PBM & pharmacy fraud, helps ensure that precious healthcare resources are used as intended. Whistleblowers have uncovered schemes between pharmaceutical companies, pharmacies and pharmacy benefit managers that cost the healthcare system billions of dollars. Whether illegal kickbacks to insurance companies, shorting prescriptions, switching prescriptions for improper reasons, or a host of other schemes, Whistleblowers have helped to correct these unacceptable behaviours through their actions. A healthcare system in crisis cannot afford such waste, and becoming a Whistleblower is an honorable way of doing your part.
As gatekeepers to the pharmaceutical companies, Pharmacy Benefit Managers ("PBMs") were to assist in reducing the costs of drugs for their clients --- private insurance companies, Medicaid and Medicare. PBMs earn billions of dollars for their services, but their close relationship with pharmaceutical companies has led to major whistleblower fraud recoveries.
Responsible for dispensing medication to patients, pharmacies often actually execute the fraudulent schemes based on relationships established between various parties, including PBMs, insurance companies and pharmaceutical companies. PBMs also own and operate specialty, retail and online pharmacies.
PBM fraud and pharmacy fraud typically involve some combination of the following:
- illegal rebate and discount agreements with pharmaceutical manufacturers;
- offering kickbacks to insurance companies or healthcare providers;
- violating contractual responsibilities by shorting prescriptions;
- switching patients’ prescriptions so as to receive a kickback or other improper reasons;
- cancelling prescriptions to conceal failures to meet contractually mandated deadlines for filling prescriptions;
- charging Medicaid or Medicare patients a higher price than others for the same prescription; and
- falsely reporting drug research grant information to government agencies.
PBM & Pharmacy fraud resulting in whistleblower rewards include:
Medco to Pay U.S. $155 Million to Settle False Claims Act Cases
Settled allegations that it:
- solicited & accepted kickbacks from pharmaceutical manufacturers to favor their drugs; and
- paid kickbacks to health plans to obtain business.
“Pressure by an employer to reduce costs and increase profits must never be allowed to coerce pharmacists into ignoring their duties to patients.”
The relators received a total of approximately $23 million.
CVS Caremark Agrees to $36.7 Million Settlement for Overbilling
Settled allegations that it illegally substituted a more expensive capsule form of the drug instead of the prescribed tablets to increase its Medicaid reimbursement.
“Switching medication from tablets to capsules might seem harmless, but when that is done solely to increase profit ... pharmacies must know that they are subjecting themselves to the possibility of triple damages, civil penalties and attorney fees.”
The relators received a total of approximately $4.3 million.
Omnicare to Pay $49.5 Million to U.S. & 43 States to Settle Medicaid Prescription Drug Related Fraud Allegations
Settled allegations that it substituted different versions of prescribed drugs, such as tablets for capsules, solely to significantly increase the cost and profit rather than for any legitimate medical reason.
“Investigating Medicaid prescription drug fraud is a top priority for the U.S. Department of Health and Human Services, Office of Inspector General.”
The relators in the case received $7.2 million.
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If you have first-hand knowledge of a major PBM or pharmacy fraud on the U.S. government, Whistleblowers Against Fraud can help you Maximize Your Whistleblower Reward. Contact us to Blow the Whistle on fraud and receive a free strategic assessment of your whistleblower information.
