Pharmacy Fraud, Past Present and Future

pharmacy.jpgMany in the healthcare industry and the attorneys who represent them in South Florida notice trends in law enforcement and criminal prosecutions that are logically preceded by increased audit activity. There are generally surges in prosecutions following increased outlays in Medicare and Medicaid spending on services, claims or equipment. Recently, the federal government has dedicated substantial resources, particularly in South Florida , to the prosecutions of physicians and clinic owners alleged to be engaged in fraud related to the administration of HIV medications; these were preceded by increased audits and overpayment demands with regard to most of the physicians and clinics later prosecuted.
With the 2006 amendments to Medicare and the creation of Part D, there was a tremendous surge in prescription drug spending by the Medicare Program, however the audit activity did not really catch up with the increased spending until recently. In South Florida, private Medicare contractors including Integrity Health, Trust Solutions and National Audit, along with the internal units of drug plan insurers have vigorously stepped up activity with fraud units conducting expansive and coordinated and almost search warrant like audits. The targets of these audit investigations often extend not only to pharmacies, but physicians who issue a large number of prescriptions for expensive medications.
The stakes can be quite high. Pharmacy owners, providers and health care administrators should be aware that these audits are not random and are generally a pretext to a referral to law enforcement authorities and should treat an audit like a search, including the use of competent counsel to preserve the provider’s rights and to avoid questioning intended to elicit incriminating information
One recent article indicates that audit activity has detected increased pharmacy fraud is found here.