In a fraud scheme that could be straight out of a made-for-TV movie, a U.S. citizen, acting as the ringleader in Russia, orchestrated a complex fraud using multiple accomplices. The operation defrauded private insurers by submitting fraudulent prescriptions through purported telemedicine visits.
While the Department of Justice announced charges against the defendants last November, seven defendants have now pleaded guilty. The perpetrators purchased pharmacies to leverage existing contracts with private health insurance companies across the country, leading to over $1.7 billion in fraudulent prescription claims. Over a 5-year period, call centers in the U.S. and other countries targeted beneficiaries, offering prescription medications without the required medical exams. The acquisition of brick-and-mortar pharmacies in various states, along with encrypted communications, allowed them to conceal the illicit activities.
Once acquired, new pharmacy management software systems were implemented to facilitate remote billing. Teams of international “billers” then submitted $1.7 billion in reimbursement claims from over 50 pharmacies across the US, resulting in private insurers paying over $500 million. In many cases, the beneficiaries never actually received the prescriptions.
The defendants, hailing from both the United States and Russia, are facing prison sentences ranging from 10 to 30 years, along with potential restitution of hundreds of millions. The ringleader of the operation, Brian Sutton, is currently at large in Russia.
Although this scheme was meticulously plotted and actions were woefully deliberate, the fact is auditors may approach well-meaning pharmacies with a dose of skepticism due to these “bad actors”.
Prior to this case, PAAS wrote a November 2021 Newsline article Telemedicine Audits: Are Your Prescriptions Legitimate? cautioning that telemedicine has become a prominent avenue for false claims to be submitted (see also November 2022 OIG Telehealth Fraud Concerns). Pharmacies need to have their own level of skepticism when filling and billing prescriptions that come as a result of a telemedicine visit. In addition to telemedicine fraud concerns, this case also highlights why it is important that signature logs are readily available and reflect an accurate signature of the patient. In its absence, there may be a question about whether the patient truly received their prescription. PAAS often sees PBMs reach out to patients directly to confirm that they not only requested a medication be filled, but also received it. Review our July article: Ensuring Audit Readiness: What PBMs Look For in Signature Logs and Proof of Delivery to help your pharmacy stay compliant.
CMS Updates HIV PrEP Supply Fee Code, Effective 01/01/2025
In December 2024, PAAS National® brought you the Medicare Part B Coverage of HIV PrEP Newsline article which provided an in-depth look into appropriately billing HIV PrEP medications to Medicare Part B. The original shift from billing these medications from Medicare Part D to Part B was effective just a few months ago (September 30, 2024, to be precise), and CMS has already instituted a change to the supply fee HCPCS billing code.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
2024-2025 Self-Audit Series #11: Controlled Substance Prescriptions
The opioid epidemic continues to make controlled substance prescriptions an increased focus for PBM audits. The potential for fraud, diversion, overdoses, and abuse remains high and pharmacies must stay vigilant when dispensing these prescriptions.
Due to federal and state requirements, controlled substance prescriptions have an increased risk of audit discrepancies. When found discrepant, PBMs typically cite as “law violations”, which are very difficult to overturn on audit appeal. Taking time to look over controlled prescriptions closely could prevent audit recoupment. Be sure to share the following tips with your pharmacy staff:
PAAS Tips:
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
New Tool on PAAS Portal – DMEPOS Article Series 2024
PAAS National® wrote a DMEPOS article series this year, which includes seven articles to be proactive in preventing Medicare Part B audits. We recently combined these articles into one tool for easy reference and review with your staff. The 2024 DMEPOS Article Series includes:
PAAS is continuously updating and creating new tools to help our members. Check out the Proactive Tips section of the Member Portal for a multitude of new and updated resources.
All employees can be granted access to the Member Portal to view these tools, along with the electronic Newsline. This also allows employees to send filling and billing questions to PAAS without having to call. If you have questions about permissions and website access visit the ‘Member Portal User Guide’ located under ‘Help’ in the left-hand navigation, or simply contact PAAS.
Understanding the Medicare Prescription Payment Plan (MPPP or M3P): What You Need to Know
As part of the Inflation Reduction Act, all Medicare prescription drug plans (Medicare Part D plans) – including both standalone Medicare prescription drug plans and Medicare Advantage (MA) plans with prescription drug coverage – will be required to offer the Medicare Prescription Payment Plans (MPPP or M3P). This option allows patients to manage their copays and deductibles evenly throughout the year, benefiting those facing high drug costs early in the year. While participation is optional, enrolled patients will have a $0 copay at the pharmacy and will receive a monthly bill from their Part D or Advantage Plan, which features 0% interest and no fees. Patients can choose to enroll or opt out of the program at any time. Enrollment can be completed via phone, mail, or website of their selected Medicare Plan Sponsor. However, if patients fail to pay their bill by the end of the grace period (typically 60 days), they may be automatically opted out. It’s important to note that pharmacies are not responsible for enrolling patients or collecting payments on an M3P bill (nor are pharmacies able to enroll patients).
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
Reap the Benefits of the PAAS National® Newsline Archive
Did you know that you can save time by searching past Newsline articles to find answers to your common questions? In fact, the Newsline archive offers articles going back to 2016! The search feature makes it simple to find that one article you know you read a while ago, but can’t seem to remember what it said.
When using the PAAS eNewsline on the Member Portal, you are able to search the Newsline Archive by date or by using a keyword. All the articles with that keyword will pop up for you. This is a convenient feature when looking for a quick answer to your question!
Some of the top Newsline articles used by PAAS analysts to answer questions are:
Try it out by looking up any keyword or you can try these below:
You can always contact us for assistance on using the Newsline search feature.
PAAS Tips:
Adjusting Quantity or Days’ Supply Disproportionately Will Cost You!
PAAS National® wants to emphasize the importance of submitting the correct days’ supply on claims. We see many audit results that could have been avoided had the pharmacy addressed the initial rejection and not bypassed the plan limit. A prevention strategy is important because these discrepancies are often difficult to appeal successfully. Pharmacy employees should be taught that a paid claim [at adjudication] may not remain paid [upon audit] and is no substitute for a claim that is billed accurately.
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
New Year, New Insurance, New Formularies!
With the new year approaching fast, many pharmacies are about to face the tedious task of getting patients’ new insurance cards (and dealing with changing formularies, copays and deductibles). As onerous as that can be, your pharmacy should consider …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
International Crime Ring Fraudulently Bills Insurers for Over $1 Billion in Telehealth Scheme
In a fraud scheme that could be straight out of a made-for-TV movie, a U.S. citizen, acting as the ringleader in Russia, orchestrated a complex fraud using multiple accomplices. The operation defrauded private insurers by submitting fraudulent prescriptions through purported telemedicine visits.
While the Department of Justice announced charges against the defendants last November, seven defendants have now pleaded guilty. The perpetrators purchased pharmacies to leverage existing contracts with private health insurance companies across the country, leading to over $1.7 billion in fraudulent prescription claims. Over a 5-year period, call centers in the U.S. and other countries targeted beneficiaries, offering prescription medications without the required medical exams. The acquisition of brick-and-mortar pharmacies in various states, along with encrypted communications, allowed them to conceal the illicit activities.
Once acquired, new pharmacy management software systems were implemented to facilitate remote billing. Teams of international “billers” then submitted $1.7 billion in reimbursement claims from over 50 pharmacies across the US, resulting in private insurers paying over $500 million. In many cases, the beneficiaries never actually received the prescriptions.
The defendants, hailing from both the United States and Russia, are facing prison sentences ranging from 10 to 30 years, along with potential restitution of hundreds of millions. The ringleader of the operation, Brian Sutton, is currently at large in Russia.
Although this scheme was meticulously plotted and actions were woefully deliberate, the fact is auditors may approach well-meaning pharmacies with a dose of skepticism due to these “bad actors”.
Prior to this case, PAAS wrote a November 2021 Newsline article Telemedicine Audits: Are Your Prescriptions Legitimate? cautioning that telemedicine has become a prominent avenue for false claims to be submitted (see also November 2022 OIG Telehealth Fraud Concerns). Pharmacies need to have their own level of skepticism when filling and billing prescriptions that come as a result of a telemedicine visit. In addition to telemedicine fraud concerns, this case also highlights why it is important that signature logs are readily available and reflect an accurate signature of the patient. In its absence, there may be a question about whether the patient truly received their prescription. PAAS often sees PBMs reach out to patients directly to confirm that they not only requested a medication be filled, but also received it. Review our July article: Ensuring Audit Readiness: What PBMs Look For in Signature Logs and Proof of Delivery to help your pharmacy stay compliant.
Matching NDCs Help Keep the Audits at Bay
Billing the wrong NDC can correlate to potential audit issues, ranging from recoupments on claims to risking contract termination. In fact, poor performance on invoice audits due to the pharmacy billing the incorrect NDC (in relation to the NDC dispensed), is a leading reason pharmacy contracts get terminated. This issue can be mitigated by …
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips:
A New Way to Administer Epinephrine – Introducing neffy®
ARS Pharmaceuticals Operations has recently introduced neffy® 2 mg, the first and only FDA-approved needle-free way to administer epinephrine. neffy® is a nasal spray used for emergency treatment of severe allergic reactions in adult and pediatric patients who weigh at least 66 pounds (30 kg). Per DailyMed, “the recommended dosage of neffy® is one spray (2 mg) administered in one nostril. In the absence of clinical improvement or if symptoms worsen after the initial treatment, a second dose of neffy® may be administered in the same nostril with a second nasal spray starting 5 minutes after the first dose.”
Did you know there is much more to your audit assistance membership than just help with audits? The PAAS Member Portal contains a wealth of information and resources to assist you with audits and member service questions. Below is a list of 6 pages found on the Audit Assistance section of the PAAS Member Portal to assist you and your pharmacy staff to be proactive when it comes to audits.
PAAS Tips: