Medicare Compliance & Reimbursement

Rx Probe's Ever-Widening Net Reels In Big Retailers...
House leaders want pharmacy chains to cough up Medicaid drug rebate records.

The House of Representatives' Energy and Commerce Committee is leaving no stone unturned in its quest to root out suspected Medicaid abuses in the pricing, sales and marketing of certain drugs.
 
In a series of letters sent Jan. 14 to five of the largest national pharmacy chains - CVS, Rite Aid, Eckerd, Walgreen and Wal-Mart - Committee Chairman Billy Tauzin (R-LA) and Oversight and Investigations Subcommittee Chairman James Greenwood (R-PA) requested documents relating to each company's Medicaid pricing and billing practices.
 
According to the letter, the pharmacies have until Feb. 13 to turn in the following information for each subject drug: total sales, average invoice price, lowest invoice price, number of units purchased at the lowest invoice price, the entity from which it was purchased, average retail price, total Medicaid reimbursement, average Medicaid reimbursement, and states with the five highest and five lowest average Medicaid reimbursements.
 
This latest inquiry is the latest salvo in a Medicaid fraud probe launched by lawmakers last June. Suspicions have mounted since previous investigations into Medicare uncovered profit incentives that steered providers toward specific companies' drugs while driving up costs to the Medicare system and its beneficiaries.
           
Lesson Learned: Medicaid drug fraud enforcers are out for blood on lax pricing procedures, so make sure this part of your compliance program is bulletproof. 
   

..But Big Fish Aren't The Only Targets
Small pharmacy owners are the latest to get nailed.

Two pharmacy operators charged with fraud against the Florida Medicaid program may be facing hard prison time.
           
Investigators with the state's Medicaid Fraud Control Unit, in concert with Florida's Agency for Health Care Administration, determined that Juan Carlos Dominguez and Stanley Davenport, owners of Miami-based Pharmed Pharmacy and Community Pharmacy respectively, were each involved in schemes to defraud the Medicaid program of hundreds of thousands of dollars.
           
Both Dominguez and Davenport and their companies are charged with one count of first-degree organized fraud and one count of first-degree grand theft - both of which carry maximum prison terms of 30 years and $10,000 fines. They are also charged with numerous counts of third-degree Medicaid fraud, which carries a maximum penalty of five years in prison and a fine of $5,000.
           
Dominguez allegedly forged prescriptions for Medicaid recipients - many of whom deny having any contact with either Pharmed or the doctors whose names were forged - and also used his pharmacy to bill Medicaid for pharmaceuticals that neither he nor his company purchased.
           
Lesson Learned: The prescription drug fraud enforcement boom is lowering on big organizations and small-time players alike.