Physician Law Blog

Summer’s almost here and the weather is heating up for HEAT, the Department of Justice’s (DOJ) task force to combat healthcare fraud. This whistleblower initiated action was brought to the attention of the government by a former pharmacist employed by PharMerica. The settlement announced today relates to allegations of dispensing Schedule II controlled drugs without a valid prescription resulting in violation of the False Claims Act for submitting false claims to Medicare for the improperly dispensed drugs.

On April 2, 2015, CMS issued notice of imposition of a $1 Million civil money penalty (CMP) against Aetna for errors reported in Aetna’s pharmacy network directory. Due to this error, many Aetna enrollees presented prescriptions to their pharmacy, only to discover that the pharmacy was not in their plan. The Medicare enrollees complained to CMS resulting in over 33% of all complaints received by CMS, of which 73% of those complaints alleged the beneficiaries were misled about in-network pharmacy coverage by Aetna’s marketing. CMS based its CMP on Aetna’s failure to disseminate clear and accurate information about the number, mix, and addresses of network pharmacies from which the Medicare enrollees could obtain covered Part D drugs. In addition, Medicare beneficiaries enrolled in Aetna’s plan have been given a special enrollment period to disenroll from Aetna’s plan and reenroll in another Part D plan. A copy of the April 2, 2015 CMS notice to Aetna is attached.