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Frier Levitt Succeeds in Challenging PBM Audit Based on Services Inadvertently Billed to Deceased Patients

Frier Levitt recently assisted an independent pharmacy with a PBM audit in which the Pharmacy Benefit Manager (PBM) alleged that the pharmacy had billed several claims to four beneficiaries who were deceased on the date of service for the claim. The PBM advised that if the pharmacy did not demonstrate the appropriate billing of those prescriptions, the claims would be reversed, and the full amount previously paid on each of...

Government Tries to Reframe Materiality in False Claims Act: What It Means for Providers

As the overseer of health benefits for millions of Americans, the Federal Government has a vested interest in ensuring the legitimacy of claims submitted for payment to Government Healthcare programs, such as Medicare, Medicaid, and Tricare. The False Claims Act (the "FCA" or the "Act"), which is perhaps the Government's strongest tool in ensuring the validity of claims, is a civil statute which carries harsh penalties for knowingly submitting, or...

Government Investigations: When Not Responding is a Non-Option

It is not uncommon for multiple, or even parallel, investigations into the same provider to take place concomitantly. To be sure, oftentimes, a pharmacy or physician practice is served with a government's investigative demand for documents or testimony only to be served with another demand by a different investigating agency or governmental body shortly thereafter. These investigations can be criminal, civil, or administrative in nature.  A recent case out of...

Overturned Conviction Casts Doubt on “Lack of Medical Necessity” to Support a Criminal Claim of Healthcare Fraud

Treating physicians and expert witnesses often have differing subjective viewpoints on the "medical necessity" for treatment or prescribing of drugs. But, when can a prosecutor's belief that a physician’s decision "lacks medical necessity" support a finding of criminality? A recent Federal court decision may cast doubt on prosecutors' legal theories relating to health care fraud cases involving alleged "lack of medical necessity." Approximately six months after a jury convicted former...

Criminal and Civil Penalties on the Rise with Healthcare Providers, Likely to Continue in 2017

In recent months, physicians, pharmacists, other healthcare providers have seen an unprecedented increase in criminal and civil penalties. Many of these missteps involve violations of the Anti-Kickback Statute (AKS), which is a criminal statute prohibiting individuals from knowingly and willfully soliciting or receiving remuneration in return for a referral for the furnishing of a drug or service for which payment may be made under a federal health care program. Oftentimes,...
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