Blog

»  Posts By    

UnitedHealthcare Wrongly Categorized Cancer Treatment as Experimental to Avoid Coverage

Recently, a class action against UnitedHealthcare was filed in the United States District Court for the Southern District of Florida. The class members in the lawsuit allege that UnitedHealth wrongly categorized proton beam radiation therapy as an experimental or investigational treatment for prostate cancer to avoid providing coverage. This suit took a drastic turn when the presiding Judge Robert N. Scola Jr. recused himself because of his personal view on...

Surprise Cuts in Medicaid Reimbursements and the Impact on Independent Pharmacies

Pharmacy Benefit Managers (PBMs) use many different tactics to increase their revenue, and spread pricing has long been a common way to generate incremental revenue from each transaction. This has become a state-wide problem in Kentucky, especially for the Department for Medicaid Services (DMS). Pharmacy costs have become the fastest growing budget items in the Kentucky Medicaid budget. In the calendar year 2018, PBMs reported being paid $957.7 million from...

Recent Aqua Pharmaceuticals Settlement Highlights Continued Focus on Speaker Programs and State Investigations

Last week, it was announced that the drugmaker formerly known as Aqua Pharmaceuticals, LLC (now Almirall, LLC) has agreed to pay $3.5 million to settle kickback claims stemming from a qui tam whistleblower suit brought by a former sales representative. Among the allegations were that Aqua improperly provided meals, tickets, gift cards and speaking engagements to dermatologists in exchange for prescribing Aqua's products. While providing prescribers items of value (such...

New Jersey’s False Claims Act Suit Against Sackler Family Highlights Growing Trend of State-Level Enforcement, Even at an Individual Level

This week, the state of New Jersey joined the long list of States to file suit against the principle members of the Sackler Family, owners of Purdue Pharma. While Purdue Pharma and the Sackler Family may have become poster children for greed in the face of the opioid epidemic, leading many states to commence politically-popular legal proceedings, this case demonstrates a growing trend of state attorneys' general offices bringing independent...

PBMs Overcharged Michigan Medicaid by $64 Million

According to a report by the Michigan Pharmacists Association and 3 Axis Advisors, Pharmacy Benefit Managers (PBMs) overcharged the state’s Medicaid Program by at least $64 million through spread pricing. The report collected data from 451 community pharmacies across Michigan, representing nearly 20% of the 2,356 retail/community pharmacies in the state to analyze PBM spread pricing – the difference between what a PBM pays a pharmacy for a medication and...