Pharmaceutical Fraud

Pharmaceutical fraud can take many forms. Whistleblowers frequently report this type of fraud to the government related to the False Claims Act.

The most common types of pharmaceutical fraud include:

Kickbacks
One common form of pharmaceutical fraud involving kickbacks is the provision of financial incentives to healthcare providers in exchange for prescribing a specific medication or medical device. This may involve pharmaceutical companies offering excessive consulting fees, extravagant gifts, luxury vacations, or even direct cash payments to doctors who prescribe their products. Such kickbacks create a conflict of interest for healthcare providers, as their decisions become influenced by personal financial gain rather than patient welfare or the best available treatment options. One way that some companies attempt to skirt anti-kickback laws is to pay “consulting fees” to physicians who prescribe their products.

Another form of kickback fraud in the pharmaceutical industry is the practice of rebate schemes. In these schemes, pharmaceutical manufacturers provide rebates or discounts to pharmacies, healthcare facilities, or insurance companies in exchange for preferential treatment, such as placement on a formulary or increased prescription volume. These kickbacks distort the competitive landscape, prevent fair market competition, and ultimately harm patients by limiting their access to a full range of treatment options.

Off Label Promotion
When pharmaceutical companies promote their drugs for uses not specifically approved by the FDA they may be guilty of off label promotion. Promoting the use of doses outside of approved ranges can also be considered off label promotion. Such promotion can harm patients and cause the government to pay for drugs that are not effective in treating a patient’s illness/condition.

Additionally, promoting drugs off label undermines the FDA's role in ensuring the safety and efficacy of pharmaceutical products, as it circumvents the rigorous approval process designed to protect patients.

Drug companies have some leeway in providing information to prescribers about off label use. However, it's important to note that while drug companies have some leeway in providing information about off-label uses, they are still restricted by certain regulations and guidelines. So it is important to consult with an experienced attorney if one believes they are aware of off label promotion

False Reporting to Medicare or Medicaid
One common form of false reporting involves billing for services or procedures that were never provided. This fraudulent practice, known as phantom billing, occurs when healthcare providers submit claims to Medicare or Medicaid for services that were never rendered to patients. This can include fabricated patient visits, diagnostic tests, or medical treatments, resulting in the fraudulent collection of reimbursements for services that never actually occurred.

Another type of false reporting involves upcoding, where healthcare providers intentionally assign higher billing codes to services or procedures than what was actually performed. By upcoding, providers seek to increase the reimbursement amount they receive from Medicare or Medicaid. This practice can involve inflating the severity or complexity of a patient's condition, or billing for a more expensive procedure than the one actually performed. Upcoding not only defrauds the government programs but also distorts healthcare data, leading to inaccurate assessments of patient outcomes and healthcare quality..

Medicare Part D Fraud
Medicare Part D, the prescription drug benefit program under the umbrella of the Medicare system, plays a crucial role in providing essential medications to millions of eligible beneficiaries in the United States - including elderly and disabled Americans . Unfortunately, with the significant amount of money involved and the complex nature of the pharmaceutical industry, instances of fraud can occur, undermining the integrity of the program and jeopardizing patient care.

Types of Medicare Part D Fraud can include:

• False claims to Medicare for medications that were not prescribed, not delivered, or not medically necessary.
• Criminals may steal the identity of legitimate pharmacies to fraudulently bill Medicare for prescription drugs that were never dispensed.
• Fraudulent schemes can involve diverting prescription drugs from their intended use or intended beneficiaries.
• Billing for brand name drugs when generic drugs are actually provided
• Billing for quantities of drugs that exceed approved limits
• Billing for drugs that have expired

Prosecuting a claim under the False Claims Act is complex. Those who believe they are aware of pharmaceutical fraud should consult an experienced attorney to determine the steps necessary to protect themselves and file a successful claim.