Dedicated to the defense of health professionals.

Insurance Audit of Pharmacy Resulted in No Discrepancy


Primary Issue:
Pharmacy was undergoing a fraud and waste audit and the insurance agency was concerned about co-pays. Under the Anti-Kickback Statute, a pharmacy cannot waive co-pays yet under Medicare and Medicaid regulations and the provider agreement, a pharmacy cannot withhold medication due to inability to pay a co-pay. The insurance agency was also concerned as it appeared that the medications were picked up after the terms in the provider agreement. The insurance agency assessed a discrepancy of fifty-thousand dollars ($50,000). The pharmacy had submitted records which showed the confirmation signatures for various medications.

Through our due diligent review of the pharmacy records, we discovered that the pharmacy was working with third-party charities who work to help beneficiaries cover co-payments. We also obtained copies of original signatures for when the beneficiaries picked up the medications. The pharmacy was utilizing a redundant system in which beneficiaries would sign hard copy receipts and later a confirmation that they had received their medications. This documentation was submitted along with the explanation and information from the charities. After reviewing all of the documentation, the insurance agency determined that there was no discrepancy owed by the pharmacy. Our attorneys have the knowledge and experience necessary to mitigate the impact a fraud and abuse audit can have on a practice. Additionally, our extensive knowledge and experience permits us to maneuver the nuances of the various Medicare and Medicaid regulations and the provider contracts to the advantage of our clients.

Areas of Law:
Fraud and Abuse Audits
Pharmacy Practice

Ronald W. Chapman, II
Jeremy L. Belanger

This information is a sample of our past results. Prospective clients may not obtain the same or similar results. Every case is different and each case must be evaluated and handled on its own merits. The circumstances of your case may differ from the results provided. The information provided has not been reviewed or approved by the Florida Bar.

Let Us Help You Now
  • Disclaimer