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.
