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As we have been noting for some time (see our previous post here), pharmacies are squarely in the cross-hairs of recent enforcement efforts by the U.S Government.  2016 looks to be no better, and in fact, is already starting out with a bang.  On January 5th, the U.S. Attorney’s Office (USAO) for the Middle District of Tenessee announced that it had reached a settlement with Nashville Pharmacy Services, LLC. and owner Kevin Hartman.  The pharmacy, which specializes in HIV and AIDS-related medications, allegedly overbilled Medicare and TennCare for pharmacy services, and will now pay up to $7.8 million to make those allegations go away.  The whistleblower in this case, Marsha McCullough, was  a former order entry technician who worked for Nashville Pharmacy Services.

According to the USAO, from February 2011 to May 2012, Nashville Pharmacy Services:

  • automatically refilled medications without a request from the beneficiary, their physician, or a person acting as the beneficiary’s agent, in violation of TennCare’s contractual requirements;
  • routinely and improperly waived TennCare and Medicare co-payments without an individualized assessment of those beneficiaries’ inability to pay;
  • improperly used pharmaceutical manufacturers’ co-payment cards to pay the co-payments of certain Medicare recipients for thirteen Medicare beneficiaries;
  • billed Medicare and TennCare for certain medications that were dispensed after the dates of death of 15 beneficiaries with either Medicare or TennCare coverage; and
  • billed Medicare or TennCare for medications that lacked a valid prescription from a licensed provider for 22 beneficiaries with either Medicare or TennCare coverage.

The case also shows the lengths the U.S. Government will go in prosecuting pharmacy allegations.  No less than four separate Government bodies were involved including:

  1.  United States’ Attorney’s Office for the Middle District of Tennessee,
  2.  Tennessee Attorney General’s Office,
  3.  U.S. Department of Health & Human Services Office of Inspector General and
  4.  Tennessee Bureau of Investigation Medicaid Fraud Control Unit.

Clearly pharmacies are a priority  enforcement target and need to get their compliance houses in order ASAP.