Tennessee Pharmacist Conducts Multi-Million Dollar Health Care Fraud Scheme
In December 2024, a Tennessee pharmacist was arrested and charged with nine counts of Health Care Fraud and six counts of Aggravated Identity Theft for operating a health care fraud scheme that resulted in over $6 million worth of false claims being submitted to several insurers.
A federal indictment returned in late December revealed that a Tennessee pharmacist who oversaw a pharmacy with several locations in Tennessee, had been submitting false claims to Medicare, Medicaid, TRICARE, and Blue Cross Blue Shield for prescription drugs that were deemed not medically necessary, were not actually dispensed to a patient, or had no evidence of being ordered by a health care provider. In many instances, the pharmacist would use the identification of other people, without their consent, to receive reimbursement for claims submitted to a health care benefit program. The pharmacies profited from these schemes by receiving fraudulent reimbursement for personal use.
The case is being investigated by the U.S. Department of Health and Human Services, Office of Inspector General, the Tennessee Bureau of Investigation, and the Department of Defense, Office of Inspector General. If convicted, the pharmacist will face up to ten years in federal prison for each count of health care fraud, and two consecutive years in federal prison for the aggravated identity theft counts. The U.S. is also seeking a money judgement of $6,524,585.44, which represents the proceeds of the fraud scheme.
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- Only bill a claim pursuant to a valid prescription on file. Billing a “test” claim or “ghost” claim is prohibited by PBMs and those claims, even if reversed, are subject to audit.
- Failure to provide a valid hardcopy can raise red flags and lead to accusations of billing false claims
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