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Types of Fraud

Medicare Part D Fraud

The Whistleblower’s Guide

Have you witnessed your employer participating in Medicare Part D fraud? If so, you may be needed to serve as a whistleblower. Whistleblowers play a crucial role in protecting both patients and taxpayers from the consequences of fraud. They may be very well compensated for their participation.

Medicare Part D Fraud is covered by the False Claims Act (FCA). This legislation was passed to prevent fraud against the government. One of its key mechanisms for discovering fraud is a qui tam provision that rewards whistleblowers with a portion of the funds that are recovered.

Before you blow the whistle, you should consider speaking to a lawyer. A lawyer can help you understand whether the activity you’ve witnessed is considered fraud and how to move forward.

Before you speak to a lawyer, it may help you to understand Medicare Part D fraud better. Below, you can learn what Medicare Part D is, what activity is criminal fraud, and what real-life examples exist of this fraud

What you will learn from this article:

What is Medicare Part D?

What is Medicare Part D fraud?

How to Identify Medicare Part D Fraud

Medicare Part D fraud examples

How to report Medicare Part D fraud

What is Medicare Part D?

Medicare Part D is a federal program that provides coverage for retail drugs. Before the program was implemented, many patients covered by Medicare were fully responsible for their drugs’ costs.

While the program is public, it is administered by private insurance companies. Most beneficiaries will be responsible for paying a small monthly premium.

Even with the cost of the premium, those covered by Medicare Part D will be able to save a significant amount of money on their prescriptions. This value has made the program a target for fraud, particularly by companies who want to benefit from selling more expensive drugs.

What is Medicare Part D fraud?

Medicare Part D fraud is a type of fraud that targets the drug benefits of Medicare enrollees. Doctors, clinics, hospitals, and other health care providers may commit this fraud by submitting false claims in order to claim reimbursement.

Health care organizations may commit this type of fraud by doing any of the following:

Submitting a claim for a name brand drug when the patient was given a generic drug
Changing the name of a drug on documentation to claim reimbursement for a drug that is not covered by Medicare Part D
Finding ways to cover the additional co-pays of patients who choose more expensive drugs by accepting assistance from that drug’s manufacturer
Double-billing both Medicare Part D and a private insurer for the same dispensed drug
Submitting a claim or documentation for a drug that was never provided to the patient

This is not a complete list of the ways that Medicare Part D may be defrauded. Whistleblowers who want to help protect Medicare may need to watch for additional signs that can help them identify fraud.

How to Identify Medicare Part D Fraud at your Organization

Those who are engaged in fraud may take steps to hide their activity from their employees or colleagues. If you suspect that there may be fraud at your organization, you should consider the following questions:

Have you been asked to alter or falsify documents that your organization is required to provide to Medicare or other regulators?
Have you spotted discrepancies in reports by others, such as altered dates or names of medication?
Have you witnessed un-expired medications or supplies being destroyed to conceal the fact that they weren’t dispensed?
Are documents being withheld from or bypassing departments/persons who would typically be responsible for reviewing them?

All of these signs may point to fraud, but there are others. Speak to a lawyer if you are concerned about behavior that is occurring at your office. You may have identified patterns that indicate fraud.

Medicare Part D Fraud Examples

The Justice Department has resolved a series of attempts to defraud Medicare Part D over the last few years. In many cases, they have only done so with the help and support of whistleblowers. The following examples of recent cases may help you determine if you are witnessing fraud.

In 2018, Pfizer agreed to pay $23.85 million to resolve allegations that it paid kickbacks to patients who chose their name-brand drugs by illegally coordinating with a charitable foundation. The scheme may have influenced patients to choose Pfizer drugs over more affordable options. This drug cost more than the maximum benefit offered by Part D, so it maximized the amount that Part D was contributing.
In 2020, Novartis agreed to pay more than $51 million to resolve allegations that it paid for Part B and Part D co-pays by using its own money. The company developed relationships with three co-pay foundations to cover patient’s drug costs when they chose Novartis-branded medications.
Ray Dixon of Baxley, Georgia, was sentenced to four years in prison for his role in a prescription drug scheme. He distributed drugs, including oxycodone, without legitimate prescriptions. In several cases, he created fake prescriptions and billed Medicare Part D for the costs. In addition to prison time, Ray was sentenced to pay nearly $2 million dollars in restitution.

Are you Ready to Blow the Whistle on Medicare Part D Fraud?

Now, you understand what Medicare Part D is, what acts may be considered fraud, and how to identify it in your organization. You’re also familiar with some examples of how Medicare Part D fraud may play out in practice. With this information, you’re ready to take the next step.

Medicare operates a fraud line that you can call to report serious violations. If sitting on information you think may considered fraud, we recommend reviewing your legal options with a confidential, no-obligation consultation with our whistleblower attorneys. Not all activity that is inefficient, wasteful, or coercive is knowingly fraudulent.

If you are considering blowing-the-whistle on a potential Part D fraud situation, review the details with our attorneys and see if you have a case today.