Fraudulent Prior Authorization Submissions Costs Pharmacy Over $1 Million

A Florida-based pharmacy plead guilty to healthcare fraud and agreed to pay over $1 million to resolve False Claims Act violations stemming from falsified prior authorizations. The pharmacy dispensed Evzio® (injectable naloxone product for emergency treatment of opioid overdose—discontinued in October 2020) which frequently required prior authorizations due to its high cost. Instead of sending the prior authorization information and/or forms to the prescribers, the pharmacy would complete the forms and, in some cases, sign the required forms. It was made to appear that the physician (not the pharmacy) was submitting the information. Pharmacy staff also provided false information to the insurer that the patients had tried and failed to successfully use Narcan®.

Become an audit assistance member today to continue reading this article. As a member, you’ll have access to hundreds of articles and receive our monthly proactive newsletter!

A pharmacy may believe they are “helping out” the prescriber by doing the prior authorization for them, but there is language in PBM provider manuals on this topic. For example, the Caremark provider manual section 5.06 states “For prior authorization, the Prescriber is required to supply additional documentation to Caremark or the Plan Sponsor to determine whether certain criteria are met for the drug to be covered under the Plan.” The restriction is intended to prevent kickbacks to prescribers from pharmacies for medication referrals, as well as falsification or manipulation of prior authorization information.

PAAS Tips:

  • Prior authorizations should be completed and submitted by prescribers, independent of the pharmacy, unless there is an explicit allowance from the PBM and the pharmacy has access to clinical information (where needed)

Erin McDonald, PharmD