Pharmacy fraud primarily occurs when Medicare is billed for a medication that was never received or when a beneficiary is intentionally provided with a different prescription drug than the one that was prescribed. Below are some examples of potential pharmacy fraud and abuse:
- False pharmacy billing;
- Payment for medication that was never received;
- Bills for brand name drugs but received generic drugs;
- Less than the prescribed quantity is intentionally provided, and the patient is not informed; and
- Prescription forging or altering.
How Can You Detect Pharmaceutical Fraud?
There are ways to detect fraud in your Explanation of Benefits (EOB). Additionally, if you have Medicare, you can see it on your Medicare Summary Notice (MSN) for:
- Prescription medications were not picked up, delivered, or even prescribed;
- Prescription drugs that were prescribed but you never had them;
- The medication prescribed is above the amount needed;
- A prescription not approved by the Federal Drug Administration (FDA);
- A pharmacy issued you expired drugs;
- You were overcharged for the prescription by the pharmacy;
- A promotional offer from a company providing you discounted medications without any prescription order;
- Other discounts that lure you into the park and want you to switch to their prescriptions; and
- A pharmacy automatically refills a prescription you no longer need but are billed for it.
What Is Fraud Involving Prescriptions?
There are different types of fraud when it comes to pharmaceutical drugs. Forgery is one of them, and it is based on creating forged prescriptions. Another is a diversion, which utilizes legal prescriptions for illegal uses. These include selling your prescription medication. Moreover, visiting different providers to obtain prescriptions for unethical uses is referred to as doctor shopping.
Furthermore, there is prescription medication abuse, which is using forged prescriptions. This prescription fraud is highly costly to physicians, hospitals, insurers, and taxpayers. Perhaps the most devastating impact of this addiction is the amount of American life it takes. Prescription abuse through the medical system is complex. It is crucial to be aware of the warning signs of this addiction. You can research LegalMatch.com for more information on this type of abuse and addiction in the medical community.
If you have been prescribed narcotics, only use them for their intended purpose. Using them beyond their intended purpose can be dangerous. Furthermore, do not share your medication with anyone. Also, educate yourself and learn from your doctor about any non-opioid options.
How to Reduce Fraudulent Activity?
Fraudulent activity occurs within the pharmacies. Patients can obtain prescriptions under pretenses, providers write illegitimate prescriptions, and pharmacies process fictitious claims.
The Academy of Managed Care Pharmacy (AMCP) “supports efforts by both federal and state governments that enhance law enforcement’s ability to combat the actions of individuals who falsify prescription information or providers who write prescriptions for patients who intend to abuse the drugs,” according to their organization. They further encourage the adoption of electronic prescribing systems that can deter fraud at the pharmacy’s point of sale.
Moreover, Health plans and pharmacy benefit managers (PBMs) can assist in fighting fraud through their pharmacy networks. They can be the first step in detecting fraud and verifying legitimate pharmacy providers. Furthermore, they can reduce the risk of false payments. For this, the AMCP can contract with authentic providers and engage with them directly.
They can also create mandatory writing stipulating that all “clean” claims be paid within a certain time frame. Through this, they can detect fraud earlier on and formulate an investigation system to ward off any potential fraudulent activity. This would allow a health plan or PBM to suspend payment when there is credible evidence of fraud.
Having these systems in place allows for accountability for each party involved. It creates a way to detect and deal with fraud earlier on. It brings the parties together to form a way to reduce fraud in the medical community dealing with pharmaceuticals. The CMS Center for Program Integrity works to identify and prosecute suspected instances of fraud within the Medicare and Medicaid programs. Lastly, AMCP encourages that adequate Congressional appropriations be awarded to those individuals combating pharmacy fraud.
What Are the Elements of Fraud In General?
As with any claim, the lawyers must formulate a plan. Pharmacy fraud attorneys must prove the elements of fraud and how they apply to the case. Certain elements must be present for the case to move forward. Below is a brief explanation of these elements and what the lawyers need to prove for the case. First is establishing intent. The party committing the act of fraud must possess the mens rea element or have a state of mind for knowing that they are committing the fraudulent act.
Second, there must be a misrepresentation of a material fact. Meaning the fact must be significant and crucial enough to misrepresent someone. It entails that the material fact must be important enough to impact an individual to act in a certain way. The fact must be sufficient enough that it falsifies the truth.
Third is inducing a party to act a certain way that can harm the other party. The party suffered harm after following the misinformation represented through fraud in the case. For instance, in a pharmacy fraud case, a pharmacist can intentionally and knowingly bill an insurance company for a medication order filled for a patient who does not exist. Then, the bill is paid by the insurance company for filling the fictitious prescription.
Therefore, in terms of proving the case, several elements of fraud are apparent. Firstly, the pharmacist intended to fraud the patient because they knowingly billed the insurance company despite no patient. Furthermore, there was a false charge for the prescription that did not exist either. Fraud is again committed because it was a misrepresentation to the insurance company for billing purposes.
The fictitious prescription serves as material fact or information. The insurance company acts upon the receipt or request for payment from the fraud pharmacist and pays the pharmacy for filling the false prescription. The insurance company unknowingly acts to its detriment since no real patient exists and is benefiting from the payment to the pharmacy for filling the fictitious prescription.
However, once the insurance company or the plaintiff realizes they have been frauded, they can seek assistance from the pharmacy fraud lawyers to file an action. The action can consist of both compensatory damages as well as punitive damages.
Lastly, if a report is filed with law enforcement, a criminal action can also be initiated against a defendant who commits a fraudulent act. It is considered a criminal offense when illegally obtaining payments fraudulently. You should be wary of your medical bills and carefully examine them. It is critical to look through the EOB sent from your insurance companies to understand your health bills.
When Do I Need to Contact a Lawyer?
Pharmacy fraud occurs frequently in the medical field. Scammers can steal and obtain unauthorized drugs. As mentioned earlier, forgery has become a common method to obtain prescriptions.
False billing has also resulted in frustration towards the gatekeepers and shows the health care system’s failure. If you are a victim of pharmacy fraud, do not hesitate to contact a local fraud lawyer to obtain information regarding your situation.
