Costly Cure

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42947095 - prescription form lying on table with stethoscope, pen and pile of pills fell out from jar. medicine or pharmacy concept. tablets and recipe.

Hepatitis C is a dangerous disease because people who have it can be infected for 30 or more years and not even know it. (Here’s a scary statistic – according to the Centers for Disease Control and Prevention (CDC), approximately 2.7 million people in the United States have chronic hepatitis C.) The viral infection damages the liver over time and a chronic infection can lead to cirrhosis, liver cancer and even liver failure. Thanks to new treatment advances, Hepatitis C can be cured with costly new medicines. These revolutionary drugs lead us to today’s Medicaid fraud case which was committed by a former clinical pharmacy manager in Tennessee.

The former pharmacy manager from Jonesborough illegally enabled TennCare (Tennessee’s Medicaid Program) beneficiaries to receive prescriptions for expensive drugs used to treat Hepatitis C. (The problem with this is that TennCare has some explicit rules when it comes to doling out drugs to treat this disease. If the patient abuses illicit substances or has limited or no scarring of the liver, they are not eligible.)

Over one-and-a-half years, the pharmacy manager falsified prior authorizations, medical lab reports, and drug test results for at least 51 Hepatitis C patients so they could receive the costly medicine. (Patient lab reports and drug tests show that they failed to meet TennCare eligibility requirements.) In addition, she made up allergies for some of the patients so they could qualify to receive the most expensive drug. In all, $4.4 million was paid by TennCare so approximately 51 patients could purchase the more expensive Hepatitis C drug. (That averages out to about $86,274.51 for each patient. Wow, that is outrageously expensive!)

The 33-year-old fraudulent pharmacy manager was sentenced to 16 months in federal prison for committing healthcare fraud. After finishing out her prison term, she’ll be on probation for three years.

There’s no motive mentioned behind today’s fraud by the former clinical pharmacy manager from Jonesborough, Tennessee, but perhaps she was trying to help her clients to receive better care. Or, maybe she benefited in some way from the number of prescriptions she issued for a particular drug. No matter how you look at it, she disobeyed government regulations and falsified patient information so that they could receive a costlier drug. In the end, it is the taxpayers that ultimately had to foot the bill for this particular Medicaid fraud scheme, a costly illness that also desperately needs a cure.

Today’s “Fraud of the Day” is based on an article entitled, Former clinical pharmacy manager sentenced for TennCare fraudposted on WCYB.com on June 26, 2017.

A former clinical pharmacy manager from Jonesborough was sentenced to 16 months in federal prison Monday for healthcare fraud, which resulted in at least a $4.4 million loss to TennCare.

Upon 33-year-old Amber Reilly’s release from prison, she will be on probation for three years. Reilly pleaded guilty in October 2016 to one count of healthcare fraud. In her plea agreement, she admitted that between October 2014 and April 2016, she falsified prior authorizations, medical lab reports, and drug test results for at least 51 Hepatitis C patients who had prescriptions for expensive drugs used to treat Hepatitis C.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.