Medicare Part D Fraud
In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which added a new outpatient prescription drug benefit known as “Part D” to the Medicare Program, to begin in 2006. The Medicare Part D Program subsidizes the cost of prescription drugs for eligible Medicare beneficiaries and relies on private contractors, called Part D Sponsors, to provide the prescription drugs to the beneficiaries. The sponsor, either directly or through pharmacy benefit managers (“PBMs”), then submits claims to the Center for Medicare and Medicaid Services (“CMS”) for the cost of these drugs and a bundle of related services.
Although the Part D program is relatively new, fraud against the Part D program is already major concern. For instance, CMS and the GAO reported that the size, nature, and complexity of the Part D program make it at particular risk for fraud, waste, and abuse. As it is widely expected that the Part D program will continue to be the target of substantial fraud in the coming years, CMS identified specific types of fraud that the Part D program is vulnerable to.
The common types of fraud, waste and abuse in the Part D program which CMS has identified include fraud by all entities in the Part D program including Sponsors, PBMs, and Pharmacies. These types of fraud include:
- Inaccurate or incomplete false prescription drug event (“PDE”) data submission;
- Billing for non-existent prescriptions;
- Catastrophic coverage manipulation;
- Bait and switch drug pricing;
- Billing for brand name drugs when generics are dispensed;
- Improper prescription drug switching;
- Failure to provide negotiated prices of a drug to a beneficiary;
- Improper payments for excluded drugs;
- Illegal marketing schemes;
- Enrollment fraud;
- Improper rebates from pharmaceutical manufacturers and wholesalers.
Attorneys in the national qui tam practice group of Pietragallo Gordon Alfano Bosick & Raspanti have extensive experience in representing whistleblowers who uncover fraud in the Part D program. For instance, the qui tam practice group currently represents the whistleblower in one of the largest FCA cases regarding the Part D program, U.S. ex rel. Spay v. CVS-Caremark, Corp., 2:09-cv-04672-RB (E.D. Pa). In that case, an experienced pharmacy auditor has alleged that CVS-Caremark has engaged in a continuous, nationwide fraudulent scheme in its role as a PBM and Part D Sponsor by (1) improperly dispensing gender-specific drugs to the opposite gender, (2) failing to provide negotiated prices of drugs to beneficiaries, (3) billing for expired drugs, (4) billing for drugs with false physician identifiers. (4) improperly dispensing prescription drugs without prior authorization, and (5) billing for drugs that exceeded approved limits. In the first major court decision regarding the Part D program, the United States District Court for the Eastern District of Pennsylvania completely denied CVS-Caremark’s motion to dismiss these allegations and the case is currently in discovery. Click here to read a copy of the Complaint and the Court’s decision.
If you believe you have information related to a claim of fraud regarding the Medicare Part D program, and would like to speak with a member of our qui tam whistleblower practice group about a potential false claims case, please feel free to contact us directly or click here.
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- Medicare, Part D, Full of Fraud Due to Lack of Oversight
- Federal Ruling: CVS Must Produce Documents Related To Alleged False Claims
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The lawyers in the national qui tam whistleblower practice of Pietragallo Gordon Alfano Bosick & Raspanti have proven, battle tested experience fighting for whistleblowers in federal and state false claims cases. The whistleblower practice group includes five former federal and state prosecutors who have:
- Recovered over $2 billion for federal and state taxpayers
- More than 30 years combined experience representing whistleblowers
- Fought some of the most complex cases brought under federal and state false claims acts
- Litigated against some of the largest companies in the United States
- Represented whistleblowers in federal and state courts across the United States
Some of our current whistleblower cases include:
Some of our successful whistleblower cases include:
Supreme Foodservice AG
St. Barnabas Health
Medco Health Solutions
Community Health Systems, Inc.
Health Diagnostics Laboratory, Inc.
Fresenius Medical Care
Doshi Diagnostic Imaging Services
Cooper Health System
University of Pennsylvania
The Boeing Company
Christiana Care Health System