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Pharmacy and Fraud

Fraud & Your Pharmacy:  Darshan: Hey, Major. It’s been a long time. So today we’re going to be talking about […]

August 07, 2018 Community Pharmacy, Law of the Land

Fraud & Your Pharmacy: 

Darshan: Hey, Major. It’s been a long time. So today we’re going to be talking about pharmacists and when we do wrong and, “Is this a big deal?” Is it the equivalent of, “You know what, a pill here and there, do we worry about them?”

Major: What are you talking about, fraud and pharmacists. Now, we defend pharmacists on the show, on the podcast, quite a bit, and for legitimacy. The thing is, we’re talking about fraud and pharmacists, so pharmacists can be involved in fraud? How is that? How does that work?

Darshan: So here’s the funny thing. Today’s news or yesterday’s news was a pharmacist in Germany was involved in diluting chemotherapy for patients, for very expensive patients, and the fact was that patients potentially died because of this dilution. And if that same situation had happened in the US, that pharmacist would very much convicted of fraud, fraud by the government, and fraud to patients. So those would be things we’re thinking about. Is that the only way? No. The dilution, which obviously would have hurt patients, for what, so that he could have a nicer house? That’s not what he went to pharmacy school for. I mean, it’s nice if he has a nice house. I have no problem with his nice house. But it shouldn’t ever happen at the price of his patients.

Major: Just to clarify, fraud is defined, and this is just strict Google definition, right, “Wrongful or criminal deception intended to result in financial or personal gain.” So in that situation, he wasn’t the most quality of an individual, just a personal-

Darshan: There you go, exactly right. And that’s the problem. Here’s the other thing, most pharmacists think that we are operating effectively under the radar. We also sort of think that we’re beyond reproach. I mean, for the longest time, pharmacists were the most trusted profession. In recent times, nurses have taken over. Clergy have come close. But pharmacists tend to be amongst the highest trusted professions, and that’s been dropping, and that’s a concern. We as pharmacists need to look back and figure out what’s happening.
The next thing that we need to look at is, is this a common enough occurrence? So does it happen every day?

Major: Are these guys just outliers that we’re hearing about?

Darshan: Yeah, exactly. These people obviously are outliers. It’s not like every second pharmacist you see is cheating and lying. But it’s happening enough that pharmacists should be aware and pharmacists should be looking out. So what does that really look like? I mean, in the last month, there have been at least three separate cases, if not more, of pharmacists being charged with being involved in fraud, and that’s obviously a massive issue. We’ll put the links in the article with the podcast, and that will be useful for you as you continue, and you can read and find links. But that’s something to consider.
Now, are the fines for fraud such a big deal? In one of the cases, the pharmacist is facing 20 years in prison on 27 counts, and another 10 years for another one of the counts, and fines could be in excess of $1.5 million. So obviously it’s going to be a big issue. People are going to be worried. Lives are going to be altered. Lives have probably already been altered.

Major: Right. We’ve established that it’s bad and that there are severe penalties, but are there any commonalities between these cases, between these situations where a pharmacist is fraudulent?

Darshan: So that’s a great question. So what I did was I did a quick search, and I’m aware of this list, and essentially the [inaudible 00:04:29] top 10 causes that the Office of Inspector General puts out for healthcare provider, healthcare fraud, and these are the top 10. I don’t know if these are- [crosstalk 00:04:37]

Major: They actually have a top 10 list. That’s crazy. Okay.

Darshan: Exactly. Number one, billing for services not rendered. Essentially you’re saying that someone came in, you gave them services. So let’s say you’re doing MTM, medication therapy management, and you never actually did it, but you billed the government anyways, billing for non-covered service as a covered service, and what that means is you’re going to a patient, and a patient who knows that their medication isn’t covered, bill it as something else just so the patient doesn’t have to bear the cost, but the government does.
Then there’s misrepresenting dates of service. You might think of that as simply putting on the wrong date, but that could also be you showing a consistent practice of changing dates so that something is covered.
Misrepresenting locations of service. So if you own multiple pharmacies, you give it for one location and not at the other. The government is looking.
Misrepresenting provider of service, so if there are multiple people involved. So let’s say you’re a pharmacy that has, let’s say an NP comes through, the NP forgets to bill, so you just bill it through the pharmacy and then you just give the NP some money, that would be fraudulent, as well.
Waiving of deductibles and co-payments. Pharmacists typically think of this as helping the patient. You want the patient to get the medication. You know what? If I don’t get an extra 10 bucks or 20 bucks or 30 bucks, that’s fine. That actually would be considered to be fraudulent, and pharmacists would face potential jail time with that. Waiving of deductibles on a co-pay, I think we just discussed that.
Incorrect reporting or diagnosis of procedures, so unbundling of services. So it’s taking … again, if you’re doing medication therapy management, you’re sort of unbundling things and fraudulently billing for one and not the other, et cetera.
Over-utilization of services, so billing excessively when that is not necessary, and that would be problematic.
Corruption. That’s kickbacks and bribery, and this is actually a pretty big one, because you keep seeing this happening over and over and over again, where you essentially go to a doctor and you go, “You know what? For every 15 prescriptions you send to me, I’ll make sure you get $100 back.” You as the doctor are happy. The patient gets their medication. I’m happy. So this is all a good thing.
And then there’s the false, unnecessary issuance of prescription drugs. So you tell the doctor, “You know what? Wink, wink, nod, nod, let’s make sure all these patients get these medications.” You get a nice kickback from the pharmaceutical company, you might get a nice little kickback from the doctor, patients are happy, but that may also be problematic.
So the question then becomes … go ahead, Major.

Major: So we’ve established that it’s possible that pharmacists can and do commit fraud, penalties are very substantial, and the top 10 causes, which we just went through, but why? What circumstances can push a pharmacist to those extremes? And we’re not talking about bad apples, we’re not talking about malintent. We’re talking specifically about the normal, the common pharmacist that just wants to get by and have the doors open the next day.

Darshan: Right. So I think the two most common mistakes I see in terms of just fraudulent cases that keep coming up-

Major: And by the way, Darshan, you’re not talking about this from an outsider’s perspective, are you? You’re actually a pharmacist?

Darshan: I’m a pharmacist and I’m an attorney, and I deal and help pharmacists all the time. That’s what I do. So I’m always glad to talk to people, I’m always glad to help people, and if people need help, I’m happy to provide that for them.

Major: I’m sorry. I totally interrupted you. You were going through the circumstances that push the pharmacist to the extreme of fraud.

Darshan: Oh, good. The two big pieces that are big pharmacists show up in the spotlight, are the following. Number one, opioids. We all know that the government has task forces. We all know that the government is looking closely. We all know that the government is monitoring anyone who’s dealing with opioids, and pharmacists are the last point before opioids are given out. If that’s true, since that’s true, when there’s an inappropriate amount of opioid being out by a pharmacist, you know that the government’s looking. And if you are giving an inappropriate patient medications that they do not need, that is very much on the top 10 list. It’s a false, unnecessary issuance of prescription drug, and pharmacists are being caught up in that.
The second one, and that’s almost as equally common, is the fact that pharmacists are using marketers to help them gain business. By itself, that is totally okay. But marketers are trying to build relationships, and sometimes they go overboard, because they don’t know what they don’t know. All they know is they’re trying to build a relationship. And when they go to build that relationship, they sometimes structure it so that it falls within the Anti-Kickback law, it falls within the False Claims Act. It may fall within the Stark law, and you’ve got to be careful. You’ve got to make sure that there are no issues, like ownership, kickbacks being given, and if they are, you may very well find yourself being exposed to criminal and civil liabilities.
So keep an eye up. Think about that as you continue.

Major: Sounds like a great idea.
So my name is Major. This is Darshan. We are the hosts of the Gavel and Pestle Podcast on the Pharmacy Podcast Network.
Darshan, do you have anything else that you’d like to add?

Darshan: No, I think this is great. I’m excited. We’ve got to do another one of these pretty soon. Stay tuned.

Major: Thanks, guys.