According to a statement released by the U.S Attorney’s Office in the Southern District of New York, five individuals were arrested the morning of March 2, 2023 as a result of defrauding government insurance plans, including Medicaid and manipulating low-income individuals out of their HIV medications from July 2020 through February 2023. This resulted in $15 million worth of illegitimate payments to the pharmacy from government insurance plans. Instead of purchasing the HIV medications through accredited distributors, the pharmacy opted to buy HIV medications from the black market, totaling over $6 million worth of purchases.
In the fraud scheme, an individual sold the black-market HIV medications to a pharmacy store owner with two pharmacy locations in Bronx, New York. He subsequently dispensed the black-market medication to patients with HIV in addition to submitting fraudulent insurance claims for profit. The other three indicted individuals were employed by the pharmacy and assisted the pharmacy owner in paying illegal kickbacks to incentivize patients to use their pharmacy for their HIV medications. To make matters worse, the pharmacy team encouraged patients to sell their HIV medications back to the pharmacy, foregoing the treatment meant to control their HIV infections. The five individuals are looking at time in prison varying from 27 to 47 years if sentenced to the maximum.
Although this is a case that shows blatant intent of actions, the basis still applies:
- Properly vet your wholesalers
- Utilize NABP’s website to check for Drug Distributor Accreditation
- Review the FDA’s website to see which wholesalers are licensed by your state
- Be familiar with the Drug Supply Chain Security Act, or the Track and Trace law, and ensure your pharmacy utilizes wholesalers who can provide pedigrees
- Get additional tips in the following Newsline articles pertaining to vetting wholesalers and distributors
- September 2020 Pharmacy Wholesaler Best Practices
- August 2021 Invoice Audit Pitfalls- Are Your Wholesalers Legitimate?
- Ensure claims are being adjudicated in accordance with a prescription
- Have your pharmacy team complete their Fraud, Waste, and Abuse Training annually to ensure your team appreciates the repercussions of fraud, waste and/or abuse of medications
PAAS’ Fraud, Waste & Abuse and HIPAA Compliance program keeps members compliant beyond training and exclusion checking. If you aren’t a member of FWA/HIPAA and are interested in saving $129 on your membership, please contact PAAS at (608) 873-1342.
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