Two recent health care fraud prosecutions of pharmacists highlight the growing risk pharmacists and others face for billing Medicare or other federal programs for medications not delivered or other prohibited practices. Pharmacists, pharmacies and their related entities or businesses should take steps to ensure their practices and processes prevent aggressive billing or other prohibited practices to mitigate exposures for potential individual and organizational liability under Federal and state criminal and civil health care fraud laws.
California Pharmacist
California pharmacist Paul Mansour faces sentencing to up to 10 years in prison after pleading guilty on April 5 to submitting fraudulent claims to Medicare for prescription drugs that were never dispensed to patients.
According to court documents, Mansour was a pharmacist at a Sierra Madre-based pharmacy, Mansour Partners Inc., doing business as Best Buy Drugs, which he also co-owned.
Mansour created fake patient profiles in the pharmacy’s digital filing system and added fraudulent prescription medication entries to these fictitious patient files that duplicated prescriptions for medications provided to real patients of the pharmacy. The Justice Department charged Mansour then submitted false and fraudulent claims for the drugs added in the fictitious patient files that had never been dispensed, billing Medicare for the fraudulent prescriptions in the names of real patients of the pharmacy. Between January 2017 and June 2022, the Justice Department claims Mansour caused Medicare to pay the pharmacy between approximately $600,000 and over $1 million as a result of the submission of false and fraudulent claims.
Mansour pleaded guilty on April 5 to one count of health care fraud. He is scheduled to be sentenced on June 28 and faces a maximum penalty of 10 years in prison.
Medicare Clinic & Pharmacy
On April 7, 2023, the Justice Department announced MedCare Clinic & Pharmacy, LLC (MedCare) will pay $213,677 to resolve allegations that it violated the False Claims Act by knowingly billing federal health care programs for medications never dispensed developed from whistleblowers’ claims in U.S. ex rel. Henry v. Pharmacy Holdings, et al., No. 3:20-cv-61 (W.D.N.C.).
The Justice Department alleged MedCare billed both Medicare Part D and North Carolina Medicaid for 200 prescription medications that MedCare never distributed to beneficiaries between January 1, 2016 and December 31, 2019.
The MedCare prosecution provides insights on some of the factors the Justice Department used to catch the false bills. According to the government’s allegations, inventory records showed that MedCare did not buy enough of these medications to fill all of the prescriptions billed to these health care programs.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by former MedCare employees Brittanie Henry and Zilphia Adcock. Under those provisions, a private party may file an action on behalf of the United States and receive a portion of any recovery. Henry and Adcock will receive $53,419.43 as their share of the settlement.
Warning To Others
The investigation and resolution of both these matter illustrate the government’s emphasis on combating health care fraud, including those from whistleblowers against pharmacies and others wrongfully billing federal health care programs. Pharmacies and others billing these programs should tighten their defense and controls to avoid exposing themselves to similar prosecutions.
More Information
We hope this update is helpful. For more information about these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297.
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About the Author
Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely-known for 35 plus years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.
A Fellow in the American College of Employee Benefit Counsel, Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading-edge work, scholarship and thought leadership on health and managed care and employer benefits legal, public policy and operational concerns in the healthcare, employer benefits, and insurance and financial services industries. She speaks and publishes extensively on HIPAA and other related compliance issues.
Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns.
For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here.
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