The U.S. Department of Justice announced on July 20, 2021 that a Mississippi pharmacist pleaded guilty for his role in a multimillion-dollar scheme to defraud TRICARE and private insurance companies by paying kickbacks to distributors for the referral of medically unnecessary compounded prescription medications that were ultimately dispensed by his pharmacies. The conduct allegedly resulted in more than $180 million in fraudulent billings, including more than $50 million paid by federal healthcare programs.
According to court documents, the 42-year-old pharmacist and co-owner of various compounding pharmacies admitted that he participated in a scheme to defraud TRICARE and other health care benefit programs by distributing medically unnecessary compounded medications by, among other things: adjusting prescription formulas to ensure the highest reimbursement without regard to efficacy; soliciting recruiters to procure prescriptions for high-margin compounded medications and paying those recruiters commissions based on the percentage of reimbursements paid by pharmacy benefit managers and health care benefit programs, including commissions on claims reimbursed by TRICARE; and routinely and systematically waiving and/or reducing copayments to be paid by beneficiaries and members, including utilizing a purported copayment assistance program to falsely make it appear as if his pharmacy and its affiliate compounding pharmacies had been collecting copayments.
The pharmacist pleaded guilty to conspiracy to defraud the United States and solicit, receive, offer and pay illegal kickbacks, and faces a maximum penalty of five years in prison. Sentencing has been scheduled for November 30, 2021. A federal district court judge will determine any sentence after considering the U.S. Sentencing Guidelines and other statutory factors. The pharmacist must also pay restitution and forfeit all assets traced to the ill-gotten gains.
According to the American Pharmacists Assocation, compounding is the creation of a pharmaceutical preparation—a drug—by a licensed pharmacist to meet the unique needs of an individual patient (either human or animal) when a commercially available drug does not meet those needs. A patient may not be able to tolerate the commercially available drug, the exact preparation needed may not be commercially available, or a patient may require a drug that is currently in shortage or discontinued. The U.S. Pharmacopeia Convention (USP) formally defines compounding as “the preparation, mixing, assembling, altering, packaging, and labeling of a drug, drug-delivery device, or device in accordance with a licensed practitioner’s prescription, medication order, or initiative based on the practitioner/patient/ pharmacist/compounder relationship in the course of professional practice.”
If you have information regarding false claims having been submitted to Medicare, Medicaid, TRICARE, other federal health care programs, or to other federal agencies/programs, and the information is not publically known and no actions have been taken by the government with regard to recovering the false claims, you should promptly consult with a False Claims Act attorney (also known as qui tam attorneys) in your U.S. state who may investigate the basis of your False Claims Act allegations and who may also assist you in bringing a qui tam lawsuit on behalf of the United States, if appropriate, for which you may be entitled to receive a portion of the recovery received by the U.S. government.
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