We are living in unprecedented times as the Justice Department announced the outcome of their 2025 National Health Care Fraud Takedown, marking one of the largest enforcement actions of its kind. Criminal charges were filed against 324 individuals, from various health care professions, for their alleged participation in a range of fraud schemes. The total intended losses amount to approximately $14.6 billion – more than double the previous record of $6 billion.
This nationwide effort involved collaboration between federal and state law enforcement agencies across the country including 50 federal districts and 12 State Attorneys General’s Offices. As part of the operation, the government seized over $245 million in cash, luxury vehicles, cryptocurrency, and other assets.
Leading up to the takedown, the CMS suspended or revoked billing privileges for 205 providers, which successfully helped prevent over $4 billion in false and fraudulent claims.
One area of focus in the investigation was the illegal distribution of prescription opioids. Authorities charged 74 individuals in 58 cases involving alleged diversion of more than 15 million pills, including opioids and other controlled substances. In one case, five individuals associated with a Texas pharmacy were charged with unlawfully distributing over 3 million opioid pills, which were allegedly sold through street-level trafficking operations.
Additionally, the DEA reported filing 93 administrative cases over the past six months aimed at revoking the prescribing or dispensing authority of controlled substances of certain pharmacies, medical practitioners, and companies. DEA Acting Administrator Robert Murphy stated:
“We’re targeting the entire ecosystem of fraud — from pill mills in Texas to kickback clinics exploiting Native communities. If you abuse your medical license to push poison or pad your pockets, we will hold you accountable.”
Telemedicine and genetic testing fraud schemes accounted for over $1.17 billion in alleged fraudulent claims billed to Medicare. According to the report, these schemes often intersect with other areas of concern, including durable medical equipment and COVID-19 testing – both of which remain priorities for ongoing enforcement efforts. In addition, approximately $1.84 billion was associated with alleged false and fraudulent claims billed to federally funded plans and private insurance for reasons deemed medically unnecessary, tied to kickbacks and bribes, or not provided at all.
PAAS Tips:
Would Your EPIPEN® Claims Pass an Audit?
PAAS National® continues to see a large number of EPIPEN® prescriptions flagged for audit, as well as targeted on OptumRx prescription validation requests. The PBMs often target EPIPEN® products due to their higher cost and confusion around proper billing practices and product substitution. Adhering to the guidance below can help avoid billing issues and reduce the risk of claim recoupment during an audit.
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:
Flu Shot Season Is Upon Us – Are You Prepared for an Audit?
As the flu shot season starts, PAAS National® wants to make sure you are ready to properly document these routine vaccines in case of an audit. Now is the time to check that you have all required documentation in place for this year’s flu shot season.
What is needed upon an audit:
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:
Days’ Supply Mistakes: A Fast Track to Recoupment
Calculating the days’ supply on a claim is something every pharmacy does throughout the workday. With a multitude of claims, clerical errors are bound to happen. What are the audit consequences when a days’ supply is billed incorrectly?
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:
Largest Health Care Fraud Takedown in History
We are living in unprecedented times as the Justice Department announced the outcome of their 2025 National Health Care Fraud Takedown, marking one of the largest enforcement actions of its kind. Criminal charges were filed against 324 individuals, from various health care professions, for their alleged participation in a range of fraud schemes. The total intended losses amount to approximately $14.6 billion – more than double the previous record of $6 billion.
This nationwide effort involved collaboration between federal and state law enforcement agencies across the country including 50 federal districts and 12 State Attorneys General’s Offices. As part of the operation, the government seized over $245 million in cash, luxury vehicles, cryptocurrency, and other assets.
Leading up to the takedown, the CMS suspended or revoked billing privileges for 205 providers, which successfully helped prevent over $4 billion in false and fraudulent claims.
One area of focus in the investigation was the illegal distribution of prescription opioids. Authorities charged 74 individuals in 58 cases involving alleged diversion of more than 15 million pills, including opioids and other controlled substances. In one case, five individuals associated with a Texas pharmacy were charged with unlawfully distributing over 3 million opioid pills, which were allegedly sold through street-level trafficking operations.
Additionally, the DEA reported filing 93 administrative cases over the past six months aimed at revoking the prescribing or dispensing authority of controlled substances of certain pharmacies, medical practitioners, and companies. DEA Acting Administrator Robert Murphy stated:
“We’re targeting the entire ecosystem of fraud — from pill mills in Texas to kickback clinics exploiting Native communities. If you abuse your medical license to push poison or pad your pockets, we will hold you accountable.”
Telemedicine and genetic testing fraud schemes accounted for over $1.17 billion in alleged fraudulent claims billed to Medicare. According to the report, these schemes often intersect with other areas of concern, including durable medical equipment and COVID-19 testing – both of which remain priorities for ongoing enforcement efforts. In addition, approximately $1.84 billion was associated with alleged false and fraudulent claims billed to federally funded plans and private insurance for reasons deemed medically unnecessary, tied to kickbacks and bribes, or not provided at all.
PAAS Tips:
Are You Billing Divigel® Correctly?
Billing packaged products according to their proper size and unit of measure is crucial for pharmacies, as this common pitfall could result in hefty recoupments from PBMs.
When it comes to billing insurance, a medication like Divigel® (estradiol) transdermal gel packets can be confusing for pharmacies, as different strengths use different billing units. Some are measured in “each”, while others use “grams”. So, why the discrepancy?
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:
When Medicaid is the Secondary Payor
Billing insurance isn’t always simple, whether it’s formulary issues, step therapy or plan limitations, it’s common for a pharmacy to receive a rejection when trying to bill a patient’s insurance. For patients with Medicaid as secondary coverage, can you simply send the rejected claim to Medicaid? Caution should be exercised.
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:
Dexcom G6/G7 Sensors: Retail vs DME
PAAS National® analysts have received numerous calls from pharmacies related to continuous glucose monitor (CGM) products made by Dexcom, particularly the G6/G7 sensors. There appears to be two different versions of Dexcom products – those labeled for “Retail” (pharmacy benefit) and those labeled for “DME” (medical benefit). Pharmacies report finding both products on wholesaler websites with different list prices and they aren’t sure which product they can buy, and which payors will pay for what product.
PAAS has spoken with Dexcom officials who confirmed the following:
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:
GLP-1 Prescriptions Remain in the Crosshairs of Auditors
GLP-1 medications continue to come under scrutiny from PBM auditors for several reasons. High cost, off-label use, rising utilization, and billing irregularities make these easy audit targets. Pharmacies must remain diligent to ensure accuracy and appropriateness when dispensing these medications to avoid recoupments.
The latest in audit recoupments have come from…
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:
COVID-19 Vaccine Update: Shared Clinical Decision-Making
The CDC recently revised recommendations for COVID-19 vaccination by (i) removing the recommendation for pregnant women to receive the vaccine and (ii) that individuals ages 6 months to 17 years may receive the vaccine using a shared clinical decision-making (SCDM) approach. The SCDM recommendations are meant to be flexible and informed by the characteristics, values, and preferences of the individual patient (or guardian) and the clinical discretion of the health care provider.
There are now five vaccines that follow the SCDM approach rather than routine, catch-up, or risk-based approach where the default is to “vaccinate, unless contraindicated”.
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:
Why Are There So Many Audits?
Many pharmacies that PAAS National® assists with audits have similar sentiments, “Why us?” or “We just had an audit with [insert PBM here]”. It can feel like it is a never-ending cycle, with shifting standards depending on which PBM is conducting the audit. At PAAS, we understand these concerns — and we’re here to help.
To support pharmacies in managing and minimizing audit risk, the PAAS portal includes a valuable resource under the “Proactive Tips”, called Audit Flags. This resource can help pharmacies identify characteristics of prescriptions that frequently trigger audits and provide insight into why they’re being flagged. While high-cost medications are commonly targeted, there are many other lesser-known reasons a claim might attract attention. For example, did you know…
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: