Wisconsin Non-Profit Healthcare Service Provider Agrees to Pay Over $500,000 for Submitting False Claims
A Wisconsin non-profit community healthcare service provider and an associated pharmacy voluntarily disclosed to the United States Attorneyās Office that one of its pharmacists submitted claims to Medicare and Medicaid that misrepresented the prescription drugs dispensed over several years, in violation of the False Claims Act. The company cooperated fully with the governmentās investigation regarding the false claims and agreed to reimburse the government $537,904.33.
The corporation provides a range of services, including outpatient mental health and pharmaceutical services. The false claims were submitted over a period of several years and involved billing Medicare and Medicaid for more expensive name brand formulations of medications when generic formulations were dispensed. Consequently, the reimbursements received were significantly higher than what they should have been.
According to its website, the non-profit service provider has an operating budget of almost $26 million annually, with about 80% coming from public funding. The pharmacy is internally operated, and the pharmacist responsible for making the false claims has been terminated.
The Executive Director of the organization issued an email stating that the Wisconsin Department of Safety and Professional Services has been duly notified about the issue. He also said that the State of Wisconsin is satisfied with the way the organization handled the matter and are not taking any further action against them.
Compliance Perspective
Allowing claims for medication reimbursement to be submitted for brand name medications that are reimbursed at a higher rate when generic medications were actually dispensed may be considered fraud, waste, and abuse, resulting in violations of state and federal regulations with sanctions.
Discussion Points:
- Review policies and procedures for verifying that brand name medications are not being reported in reimbursement claims submissions when generic medications are being dispensed.
- Train staff involved in the claims submission process to verify that medications dispensed are the medications being submitted for reimbursement.
- Periodically audit submitted claims by comparing medications used with medication billing to ensure they agree.
