Health Law Alliance is pleased to announce the successful resolution of numerous federal and state cases involving significant inventory shortfalls, including the dismissal of criminal charges and civil settlements for fractions of the dollar amount on claims paid.
As discussed below, Health Law Alliance (HLA)’s attorneys specialize in the defense of PBM audits and inventory discrepancies. We could not be more pleased to obtain the outcomes discussed below on behalf of clients.
PBM Audit Case Study #1
Commonwealth of Massachusetts v. Pharmacy & Owner. Following a PBM audit that noted significant inventory discrepancies, the State of Massachusetts Attorney General's Office opened an investigation.
After a lengthy investigation, Owner and pharmacy were both indicted and charged with criminal offenses that carried penalties involving lengthy prison sentences and exclusion. The 14-count indictments alleged that Owner billed Medicaid and other insurance plans almost $500,000 for 37,000 units of Zegerid, a heartburn medicine, even though the pharmacy's records indicated that the pharmacy had only purchased 12,000 units, a discrepancy of 25,000 units.
In addition, the indictments charged Owner with crimes relating to the dispensing of controlled substances, including accepting cash for prescriptions covered by MassHealth.
Following the criminal charges, the HLA team determined that the best strategy was to win in court, and pushed for an immediate trial. As a result of HLA's work, the Attorney General's Office dismissed all 14 counts in both indictments completely, permitted the pharmacy to remain in network, and did not exclude Owner.
PBM Audit Case Study #2
United States v. Pharmacy & Owner: Following PBM audits that noted inventory discrepancies, the U.S. Attorney's Office for the Eastern District of Pennsylvania, DEA and HHS-OIG opened an investigation.
After a review of the evidence, federal prosecutors alleged that Owner and his pharmacies had billed Medicare for approximately $6.5 million in compound creams across multiple pharmacies even though the pharmacy’s records indicated that they had never purchased the APIs in those creams.
In addition, the government alleged that Owner had violated laws relating to controlled substances, including Schedule II substances.
Following these threatened charges, the HLA team determined that the best strategy was to convince federal prosecutors not to file criminal charges and resolve the case. As a result of HLA's work, Owner was not charged criminally and instead settled the matter civilly for $2.5 million (62% less than the alleged discrepancy), admitted no wrongdoing, and was not excluded.
PBM Audit Case Study #3
Commonwealth of Pennsylvania v. Pharmacy & Owner: Following PBM audits that noted inventory discrepancies, the State of Pennsylvania Attorney General's Office opened an investigation.
After a lengthy investigation, the Attorney General moved to indict both the pharmacy and Owner on criminal felony charges for billing Medicaid nearly $600,000 for dispensing medications that were never provided to customers, either because the pharmacy never had them in stock or had sold them to another company for financial gain.
After analyzing the case, our HLA team determined that the best strategy was to negotiate the most favorable resolution possible. As a result of HLA's work, the Attorney General's Office declined prosecution of Owner, a particularly noteworthy accomplishment given his citizenship status.
Instead, as part of the settlement, the Attorney General's Office agreed to charge the corporate entity, which permitted Owner to avoid criminal charges and exclusion. Happily, Owner now can look forward to a life in this country with his family.
HLA Specializes in PBM Audit Defense
Finally, please note that the above cases are public matters, and HLA cannot discuss the numerous other inventory cases that have been resolved successfully before they became public. Here, at the Health Law Alliance, our firm’s mission is simple: use unmatched experience and insight to defend our clients against insurance conglomerates, the federal government, and state agencies. We used to work for them. Now let us fight for you. Contact us today for a consultation. We can help.
MORE ARTICLES BY CATEGORY
Health Law Alliance Earns Reinstatement for DME Supplier Whose Medicare Billing Privileges Were Unjustly Revoked
Due to Health Law Alliance’s advocacy, a prominent DME vendor in Texas had their billing privileges reinstated this week, without having to jump through the arduous, costly hoops of a fair hearing in front of an Administrative Law Judge or a Departmental Appeals Board review.
Read More >>Balancing Patient Access and Privacy in Audio-Only Telehealth
Address the specific compliance and privacy challenges associated with audio-only telehealth services. This article will provide telehealth providers with actionable strategies to ensure compliance with privacy regulations, such as HIPAA, while effectively using audio-only visits to increase access to care.
Read More >>10 Telehealth Fraud Red Flags (and How to Avoid Them)
Provide telehealth providers with a concise guide to recognizing and mitigating potential fraud risks. Each “red flag” will highlight a common scenario that could indicate fraud vulnerability, followed by practical steps to address it. With clear, actionable insights, the article will be an essential resource for telehealth providers aiming to safeguard their practice.
Read More >>DOJ Files False Claims Lawsuit Against Nationwide Specialty Wound Care Provider
The U.S. Department of Justice has filed a civil action against Vohra Wound Physicians Management, alleging various schemes to submit false claims for payment to Medicare. Learn more about the ongoing lawsuit and how Health Law Alliance supports wound care providers to avoid legal scrutiny.
Read More >>
