Rx for Fraud

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

A 52-year-old Decatur, Georgia man was recently sentenced to prison for committing healthcare fraud. He defrauded TRICARE and other insurance companies out of more than $6.5 million by using a Pensacola, Florida pharmacy to fill fraudulent prescriptions. While many instances of prescription fraud involve controlled substances such as opioids, today’s fraudster concocted a scheme that involved submitting bogus prescriptions for compounded pain cream, scar cream and wellness capsules.

For nearly two years, the man from Decatur conspired with four others to collect and share the personal information of victims, forge the prescriptions, then submit them to the Pensacola pharmacy. The individuals who supposedly needed the prescriptions never saw or spoke with a doctor. (They were unaware that their names and personal information were used to obtain the unnecessary prescriptions.)

One co-conspirator worked for a doctor in Georgia. He was responsible for forging the prescriptions for the compounded drugs despite not being licensed to write prescriptions. Today’s fraudster also paid another man and woman (a.k.a. sales representatives) to provide him with the personal information and insurance cards of the people the prescriptions would be issued to. (Note that these victims were NOT patients of the Georgia doctor.) Another woman, who was recruited to help the person who forged the prescriptions, assisted with processing and submitting the prescriptions. (The co-conspirators were paid a nice commission in exchange for their participation.)

According to today’s article, the Pensacola pharmacy processed $6.5 million in fraudulent prescriptions for TRICARE and other insurance companies. (The pharmacy paid the Decatur fraudster a 50% commission for each prescription that was paid for by insurance.)

The man from Decatur was sentenced to eight years in federal prison for committing healthcare fraud. (He was also convicted of money laundering and wire fraud on top of that.) In addition to the time behind bars, the fraudster was also ordered to pay $6,540,348.48 in restitution to TRICARE. He must pay a forfeiture money judgment of $1,480,931.74. (Easy come, easy go.)

The man who was responsible for forging the prescriptions is awaiting sentencing following a guilty plea in a separate, but related case. One sales representative was sentenced to 21 months in prison, while the other sales representative and the prescription processor both received probation for their parts in the crime. The president and part-owner of the pharmacy is awaiting trial. (It looks like the Rx for this crime is paying back time and money. I’m guessing the realization of the punishment probably didn’t taste so good going down.)

Today’s “Fraud of the Day” is based on an article, “Feds: Georgia man sentenced in multi-state TRICARE fraud scheme tied to Pensacola pharmacy,” published by the Pensacola News Journal on August 2, 2019.

A Georgia man was sentenced to federal prison for his role in a scheme allegedly involving a Pensacola pharmacy that ended up defrauding insurance companies out of more than $6.5 million.

Michael Scott Burton, 52, of Decatur, Georgia, was sentenced Thursday to eight years in federal prison, according to a news release from U.S. Attorney Lawrence Keefe. He was convicted of money laundering, conspiracy to commit health care fraud and wire fraud, and conspiracy to commit money laundering.

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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.