Health Law Alliance is pleased to announce that a self-disclosure filed under Anthony Mahajan’s oversight on behalf of a pharmacy that allegedly dispensed Humira improperly was recently accepted by OIG. As we have noted, OIG self-disclosures may be an effective solution to PBM audit risk.
OIG’s Self-Disclosure Protocol
The U.S. Department of Health and Human Services, Office of the Inspector General (OIG), encourages providers to voluntarily report self-discovered evidence of potential fraud through the Health Care Fraud Self-Disclosure Protocol.
As we have written about in detail, a discrepant PBM audit may permit providers to learn about and resolve potential liabilities to government healthcare programs through the OIG self-disclosure process.
In short, self-disclosure often presents an excellent opportunity for providers to limit their exposure under administrative, civil, and maybe even criminal law, but the determination whether to make such a voluntary disclosure is extremely complex and must be carefully vetted by experienced healthcare defense attorneys.
The Pharmacy’s Self-Disclosure
In this case, following a PBM audit that identified discrepancies, our attorneys worked closely with the pharmacy to determine whether a self-disclosure was advisable.
The analysis is highly dependent on the specific facts of each case, and a collaborative decision was made that a self-disclosure would be the most effective manner in which to resolve potential liabilities under the False Claims Act and Civil Monetary Penalties law.
Accordingly, following a submission made pursuant to the Self-Disclosure Protocol, Delmar Pharmacy agreed to pay $218,129.26 for allegedly submitting claims to Medicare for Humira for a patient that was delivered by Delmar Pharmacy but not dispensed by the pharmacy.
HLA Specializes in PBM Audit Defense and OIG Self-Disclosures
PBM audits often target high-reimbursing products, such as Humira, and the cost of such products means that a provider’s liability can be extremely high if there are errors. OIG’s acceptance of the self-disclosure, however, effectively limits the pharmacy’s liability for the claims at issue.
In short, PBM audits may identify potential areas in which providers can use OIG’s Self-Disclosure Protocol to limit their exposure on government claims.
At Health Law Alliance, our experienced healthcare defense attorneys are specialists in all relevant self-disclosure protocols and procedures. Indeed, our attorneys possess the background and experience necessary to guide clients through these complex decisions and assist with each step of the self-disclosure process. Contact us today for a free consultation.
Triumph Over Optum: HLA’s Tenacious Advocacy Reverses Optum’s Termination of a Texas Pharmacy
Health Law Alliance successfully reversed Optum’s termination of a Texas pharmacy from its network, protecting the pharmacy from severe financial and reputational damage. Our healthcare attorneys used strategic legal expertise and negotiations to overturn the decision, ensuring the pharmacy could continue serving patients. This victory highlights our dedication to strong advocacy and proven results.
Read More >>Enforcement of Arbitration Clauses in PBM Network Agreements: A Guide for Pharmacy Owners
This article explains arbitration clauses in Pharmacy Benefit Manager (PBM) network agreements, outlining when these clauses can be enforced and how they affect dispute resolution for pharmacies.
Read More >>U.S. Justice Department Investigates Alleged Medicare Fraud Involving COVID-19 Test Kits
The U.S. Justice Department is investigating allegations of Medicare fraud, where senior citizens' ID numbers were used to order unwanted COVID-19 test kits. Learn more about the ongoing investigation and its implications.
Read More >>HLA Convinces Optum to Reverse PBM Audit Termination
Health Law Alliance is pleased to announce that Optum recently agreed to reverse its network termination of a Texas pharmacy client despite significant claim discrepancies based on inventory shortages, patient denials, and other alleged violations of the terms and conditions of the Provider Manual and network enrollment agreements.
Read More >>