Medicare Part D fraud can happen in many ways. Whistleblowers can stop Medicare Part D fraud by using the False Claims Act, whether the fraud is committed by Part D prescription drug plan sponsors, pharmacy benefit managers (PBMs), pharmacies or doctors.

Medicare Part D prescription drug 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.

Common types of Medicare Part D fraud

Some of the ways fraud can occur in Medicare Part D plans include:

  • 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 who 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.

If you are aware of Medicare Part D fraud and want to know how you can stop the fraud, protect your job and receive a reward, 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. Keep in mind that timing is important in whistleblower cases.


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