Recently, a former Aegerion Pharmaceuticals Inc. salesman, Mark Moffett, was found guilty, by a federal jury, of conducting a drug fraud scheme that cost Medicare and other insurers more than $1.8 million. According to federal prosecutors, Moffett faked patient histories, diagnoses and certain test results, all in an effort to cause claims for Aegerion’s cholesterol treatment, Juxtapid, to be approved by payors, including PBMs. While Moffett had argued that any errors were unintentional or done out of a good faith effort to get patients the medications they were prescribed, the jury found him guilty for submitting fraudulent prior authorizations to Medicare and other insurers, with Moffett now facing up to 20 years in prison.
This case, and other recent cases, should serve as an important reminder to pharmacists and pharmaceutical manufacturers that aiding doctors in the prior authorization process could have serious consequences, especially when the prior authorizations contain omissions and/or misrepresentations. Any third party that is acting in this capacity, including pharmacies, should have comprehensive policies and procedures (“P&Ps”) in place to avoid situations where the pharmacy is involved in making misrepresentations to Medicare, Medicaid, or other private payor. In that respect, Frier Levitt offers flat fee services aimed at providing pharmacies, across the country, with robust P&Ps regarding Prior Authorization activities. In addition, Frier Levitt offers “legal audit” services, which include reviewing and making recommendations regarding a pharmacy’s billing practices, point-of-sale claims submission procedures, prior authorization practices, copayment collection practices, payor contracting status, relationships with referral sources, and inventory/record-keeping P&Ps. Contact Frier Levitt today to learn more.
