The Department of Justice (DOJ) has announced a nationwide health care fraud takedown, involving 455 defendants and over $6.5 billion in allegedly false claims. The cases spanned 56 federal districts and 45 states and territories, with asset seizures totaling over $182 million.
According to the DOJ, many of the cases began with discrepancies in records such as drug purchases, inventory, dispensing records, prescriber patterns, patient information, marketing arrangements, and controlled-substance records. When these records did not line up, what started as an audit or payment review turned into a full-blown fraud investigation.
In several high-profile cases, pharmacies were accused of billing Medicare for drugs that were never dispensed or lacked sufficient inventory to support claims. For example, in Hawaii, the government alleged that a pharmacy billed Medicare for drugs it did not dispense and had insufficient inventory to back up certain high-cost product claims.
Pharmacy owners are being warned that even legitimate explanations for discrepancies can be scrutinized by auditors and investigators. Factors such as timing differences, partial fills, returns, reversals, secondary supplier purchases, central-fill arrangements, or reporting errors may be reviewed in detail during an audit or investigation.
The DOJ's takedown highlights the importance of maintaining accurate records and being prepared to explain any discrepancies that arise during audits or investigations. Pharmacy owners are advised to ensure they have a clear understanding of their inventory controls, loss reporting, access restrictions, and discrepancy investigations to avoid potential False Claims Act cases.