Home Health & Hospice Week

Perhaps the top activity for state and federal fraud busters these days is following pharmaceutical money through the complex health care system.

That's the word from two federal enforcement officials who spoke at a June 3 briefing by the Taxpayers Against Fraud Education Fund.

State Medicaid fraud recoveries are low compared to Medicare recoveries, but Medicaid takes will likely rise as cases against pharmaceutical manufacturers and others in the prescription-drug supply chain come to light, said Jim Sheehan, associate U.S. attorney for the Philadelphia region.

States Take the Lead On Drug Fraud Suits 

States, rather than the federal government, will originate most pharmaceutical cases because they have the developing expertise and economic incentive to do so, he said.

Pharma cases will involve "all kinds of payments back and forth within the industry," that may be intended to induce physicians to prescribe one medicine rather than another, Sheehan said.

Other pharmaceutical cases in the works target companies that use "loopholes" to give bigger rebates to other buyers than Medicaid, violating Medicaid "best price" provisions.

Additional cases involve combinations of best-price violations and kickbacks, he said, such as a drug company's saying it can't offer a large buyer a price better than Medicaid gets, but it will give the buyer $3 million instead.