Be Aware of Federal Crackdown on Health Care Fraud

Across the country, health care fraud affects all areas of the healthcare system, but how does it affect your pharmacy? Bad actors in pharmacy give validation to PBM audit practices, adding to the audit burden. PBMs leverage these audits as a method to keep the “bad actors” out of the health care field and save Plan Sponsors, and taxpayers, money. 

Certain individuals validate PBM audit practices, thereby contributing to the overall audit burden. This is, at least in part, an effort to prevent unethical participants from entering the healthcare field and to help Plan Sponsors and taxpayers reduce costs.

The U.S. Department of Health and Human Services (HHS) and the U.S. Department of Justice (DOJ) have announced the formation of the DOJ-HHS False Claims Act (FCA) Working Group. This is a new joint initiative to strengthen enforcement efforts against health care fraud. The False Claims Act is one of the most effective tools for addressing fraud and this group formalizes a coordinated strategy to pursue high-priority violations.

The group is encouraging whistleblowers to report fraud, waste and/or abuse in priority areas. For pharmacies, the increased scrutiny will be on Medicare Advantage operations, pricing practices and network compliance. PAAS will be watching closely to see how auditors will scrutinize these areas going forward.

PAAS Tips:

• Be sure to send your audit notice or results to PAAS National^® right away for the best guidance
  • Review April 2025 Newsline article, Audit and Appeal Due Dates: Stay Ahead of the Clock with These Essential Tips for more information on getting the process started
  • Review Getting Help with an Audit for additional guidance
• Make sure your pharmacy has implemented a robust FWA compliance program, including written policies and procedures, compliance training, employee code of conduct, conflict of interest and business ethics. Protect your pharmacy by enrolling in the PAAS National^® FWA/HIPAA Compliance Program today.

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Erin McDonald, PharmD

Analyst at PAAS National^®

I graduated from the University of Missouri-Kansas City and spent my first few years working for a large chain pharmacy in Green Bay, Wisconsin.I made the jump to Long Term Care and spent the past 12 years in that pharmacy setting.Working in both fields has given me a solid background to understand and help independent pharmacies navigate some of the aches and pains that come with audits and other pharmacy-related questions and concerns.

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