In April 2016, pharmaceutical company Warner Chilcott was sentenced to pay $125 million for its role in allegedly providing kickbacks to prescribing physicians as well as its submission of false, inaccurate, or misleading prior authorization requests to federal health care programs for their medications, Atelvia and Actonel. As part of the sentence, Warner Chilcott will pay nearly $200,000 in restitution to insurance payors Humana and Blue Cross Blue Shield of Massachusetts in connection with claims based on false or manipulated prior authorizations.
In essence, it is alleged that Warner Chilcott paid illegal kickbacks to doctors in exchange for referrals of prescriptions for Atelvia and Actonel, which constituted violations of state and federal False Claims Act according to a United States District Court judge in Boston. According to the United States Department of Justice (DOJ), the pharmaceutical manufacturer also falsified and/or manipulated prior authorization information submitted to payors such as Humana and Blue Cross Blue Shield of Massachusetts, including when prescribing physicians refused to submit such information on behalf of its patients. In order to do so, the DOJ also alleged that the manufacturer’s managers and sales representatives “accessed patients’ protected health information in violation of the HIPAA law and regulations that safeguard the privacy of confidential health records.” While one former Warner Chilcott executive was eventually acquitted of criminal charges for allegedly violating the federal anti-kickback statute in mid-June 2016, several other Warner Chilcott employees pleaded guilty to a litany of criminal charges ranging from health care fraud to criminal violations of HIPAA in connection with their role in Warner Chilcott’s scheme to defraud private and public payors.
Frier Levitt counsels providers who are faced with investigations of pharmaceutical manufacturers’ roles in the submission of prior authorization information to both private and public payors. Our extensive and specific industry knowledge and experience in dealing with commercial and governmental healthcare audits—including those that purport to investigate prior authorization submissions for prescriptions subject to one of the Food and Drug Administration’s Risk Evaluation and Mitigation Strategy programs—is critical to helping our clients navigate the regulatory quagmire which surrounds the submission of healthcare claims to ultimate payors and their agents. Contact Frier Levitt today to speak to an attorney.
