The retail value of prescription drugs filled annually in the United States exceeds $300 billion per year. A large proportion of those prescriptions are paid by government-sponsored health insurance plans such as Medicaid, Medicare Part D, TRICARE, or the Federal Employees Health Benefits Program. The immense size and scope of the prescription drug industry makes it relatively easy for pharmacy chains to engage in behavior that results in fraud upon the Government.
Common pharmacy fraud schemes include:
- Prescription drug switching – substituting a more expensive drug for a cheaper one
- Billing for a false or nonexistent prescription
- Billing multiple payors for the same prescription
- Billing for brand name drugs when generic drugs are dispensed
- Filling less than the prescribed quantity of a drug
Real World Examples of Recent Pharmacy Fraud False Claims Act Cases:
- 2011: CVS paid $17.5 million to resolve claims that it submitted inflated prescription claims for Medicaid patients who were also eligible for private insurance. Instead of billing Medicaid only for the co-pay amount the patient was responsible for, the pharmacy billed for the entire cost of the prescription. The claim was brought by a CVS pharmacist, Stephanie LeFlore, who received $2.595 million as her share of the settlement.
- 2006–2008: Bernard Lisitza, an Illinois pharmacist filed three separate whistleblower lawsuits against pharmacy chains for improperly switching the medications of Medicaid patients to more expensive versions of the same drug. Specifically, the pharmacies were substituting medications prescribed in capsule form for the tablet form, and vice-versa, thereby increasing the reimbursement rate from Medicaid. In 2008, Walgreens paid $35 million and CVS paid $36.7 million to resolve the whistleblower claims. In 2009, OmniCare paid $49.5 million to resolve similar claims. Mr. Lisitza received just over $10 million dollars as his combined relator's share from the three settlements.