Medicare Part D Fraud, Prescription Drug Plans and Whistleblowers

Medicare Part D sponsors, as well as pharmacy benefit managers (PBMs), pharmacies, and doctors, may commit fraud involving Medicare prescription drug plans in many ways.

The Part D plans - which are operated under contract with private insurance companies to provide Medicare prescription drug coverage - are susceptible to fraud that is difficult for regulators to uncover without the help of whistleblowers. Some Medicare Part D fraud examples can be found below.

If you know fraud involving Medicare Part D or prescription drug plans and want to know how you can protect your job and receive a reward by reporting the fraud, consider discussing your case at no cost with the whistleblower attorneys at Phillips & Cohen. The firm has significant experience with prescription drug plan cases and a substantial track record protecting whistleblowers and winning financial awards for them.

Some of the more common Medicare fraud schemes by Part D sponsors, PBMs, pharmacies and doctors involving Medicare prescription drug plans are:

  • Part D sponsors misrepresenting their benefit offerings when submitting bids to CMS for Part D contracts. Part D sponsors must submit bids on an annual basis in order to enter into or renew a Part D contract.
  • Part D sponsors submitting false risk adjustment data to CMS in order to claim larger payments from CMS.
  • PBMs, which process prescription drug event (PDE) records on behalf of Part D sponsors, submitting inaccurate PDE records to CMS that result in overpayments to Part D sponsors.
  • Pharmacies charging more than their "usual and customary price" for prescription drugs when billing Medicare prescription drug plans.
  • Pharmacies filling prescriptions written by providers that have been excluded from Medicare or filling prescriptions from doctors that don't exist.
  • Pharmacies improperly billing for brand name drugs when prescriptions are actually filled with generic drugs, billing for expired prescription drugs, dispensing drugs to beneficiaries without a prescription, or filling a prescription written by a provider without the power to prescribe, such as a massage therapist or acupuncturist.
  • Doctors accepting kickbacks and bribes in exchange for prescribing drugs. Drug manufacturers' rebates also have been used to bribe doctors into writing prescriptions.

Phillips & Cohen lawyers' free evaluation of your case is confidential. Our lawyers can explain how whistleblower laws might apply in your case and detail the rewards and job protections that whistleblowers are offered through the False Claims Act. Keep in mind that timing is important in whistleblower cases.

(Read more about choosing a whistleblower lawyer.)