A recent DoJ press release (below) is a stark reminder for specialty pharmacies that they need to ensure strict compliance with federal and state laws and regulations or risk getting a severe spanking in their bank accounts….. and, heavens forbid, possibly even jail time.
The short story below is that a whistleblower at a manufacturer let the cat ‘outta de bag regarding the filing of fraudulent Medicare claims. Much of the ‘fraud’ was related to the waiving copays without proof of financial hardship way back in 2017-18. But, the hanky-panky also extended to fraudulent handling of prior-authorizations and even patient clinical information.
So, the stroll down this path cost Solera Specialty Pharmacy a cool $1.3 million. Ouch!
All specialty pharmacies should spend a fraction of that amount to implement oversight protocols to spot any deviations from claim submission standards (usually through frequent audits).
Remember…….there may be a whistleblower looking over your shoulder even now 👀
Solera Specialty Pharmacy Agrees to Enter into Deferred Prosecution Agreement
Company and CEO to Pay $1.31 Million for Submitting False Claims for Anti-Overdose Drug
Wednesday, July 13, 2022 — Florida-based Solera Specialty Pharmacy has entered into a deferred prosecution agreement and agreed to pay a $1.31 million civil settlement to resolve allegations that it submitted fraudulent claims to Medicare for Evzio, a high-priced drug used in rapid reversal of opioid overdoses.
According to Solera’s admissions in the criminal and civil agreements, the pharmacy dispensed Evzio from January 2017 to May 2018. During that time, Evzio was the highest-priced version of naloxone on the market and insurers frequently required the submission of prior authorization requests before they would approve coverage for Evzio. Solera completed Evzio prior authorizations forms in place of the prescribing physicians, including instances in which Solera staff signed the forms without the physician’s authorization and listed Solera’s contact information as if it were the physician’s information. In addition, Solera submitted Evzio prior authorization requests that contained false clinical information to secure approval for the expensive drug. Finally, Solera waived Medicare beneficiary co-payment obligations for Evzio on numerous occasions without analyzing whether the patient had a genuine financial hardship.
“Pharmacies, like all Medicare providers, must submit accurate claims,” said Principal Deputy Assistant Attorney General Brian M. Boynton, head of the Justice Department’s Civil Division. “This settlement demonstrates…………………….