The Medicare Part D prescription drug program has had an extraordinary amount of fraud. If you have evidence of a physician, pharmacist or plan sponsor engaged in health care fraud, you may report your information to the Department of Justice through a False Claims Act lawsuit and potentially earn a reward of between 15 and 30 percent of the government’s recovery from the case.
Our whistleblower attorneys will evaluate your evidence of Medicare Part D fraud in a free, confidential initial consultation.
Potential Violations of the False Claims Act
Part D prescription plan sponsors are required to submit accurate drug pricing information to the U.S. Government. If a Part D sponsor submits false data, Medicare recipients on Plan Finder cannot make an informed choice about their coverage and CMS overpays for the reimbursement of drugs.
Pharmacies are not permitted to dispense a Schedule II drug without a prescription under the Controlled Substances Act. Schedule II drugs, for example, have a high potential for abuse and can cause significant harm if used improperly. The drugs on this list include narcotics like oxycodone and morphine. In order to be dispensed, they must have a valid prescription. Drugs dispensed without a valid prescription are not eligible for reimbursement payments under Medicare Part D.
CMS makes prospective payments to sponsors monthly based on estimates in their bids at the beginning of the year. At the end of the year, the actual costs of the sponsor are reconciled with these payments to determine whether Medicare owes additional money or the sponsors owe Medicare. One area where a false claim might arise is due to the inaccurate reporting of rebates and other price concessions during this reconciliation.
Dual Eligible Patients
Some patients have drug coverage through both a private insurance program and a government plan or two government plans. For example, an eligible individual might enroll in coverage for both Medicare Part D and a state Medicaid plan. If a pharmacy or PBM submits to both insurance programs improperly, the government will overpay and a false claim is generated.
Both pharmacies and physician prescribers have been investigated for possible prescription drug fraud by the government and the media. There are a number of potential fraudulent schemes whereby program participants steal money from the system. These may involve writing prescriptions to individuals that do not need them or filling phantom prescriptions that are not given to the patients.
About Medicare Part D
Medicare Part D offers optional prescription drug coverage to Medicare Part A or Part B beneficiaries. It was passed in 2003 as part of the Medicare Modernization Act. It subsidizes the prescription drug costs and insurance premiums for beneficiaries on Medicare. It went into effect in 2006 so it is still relatively new. More than 35 million Americans are now enrolled in the program and the number is expected to increase to more than 40 million in 2015. The cost to the government is projected at $85.2 billion in gross spending in 2015.
Part D is run by plan sponsors. Plan sponsors submit a bid every year to CMS concerning the cost of their Part D plans. A beneficiary who signs up for a Part D plan is required to pay a monthly premium. There is then an initial deductible of up to $320 (or so). After reaching the deductible, there is either a copayment or coninsurance due on prescriptions obtained through the program. At a certain amount of spending on covered drugs ($2,960 in 2015), there is a coverage gap (also known as the “donut hole”) Before the Affordable Care Act, participants were responsible for 100% of the costs during the coverage gap. Now, enrolles pay 45% of the price for brand-name drugs and 65% of generics in 2015. Following out-of-pocket spending of $4,700 in 2015, Medicare provides catastrophic coverage with only a small coinsurance or copayment for the rest of the year.
The Benefits of Reporting
The Right Thing to Do
Whistleblowers have become an increasingly important tool for law enforcement agencies. Without tips from individuals with non-public information, a company’s violation of the Medicare rules might cost the government tens or hundreds of millions.
The U.S. Government pays out hundreds of millions of dollars every year to whistleblowers under the False Claims Act. The law permits the filing of qui tam lawsuits by relators on behalf of the government. The Department of Justice investigates the information in the lawsuit. If there is a recovery for the U.S. Government and the relator is eligible, a reward of between 15 and 30 percent of the total amount may be awarded to the whistleblower.
Section 3730(h) of the False Claims Act protects a whistleblower from retaliation by their employer. It allows individuals to sue their employer for compensation including back pay, reinstatement, attorneys’ fees and other relief to make the individual whole.