Transcript mmPHR Use Cases

mmPHR Use Cases
Oxyconton Fraud Business Model
Rubina Lakhani
March 2, 2016
Business Model
Insurance
Company
Pharmacy
[1..Pa]
Rxb2
Rxa1
Marketer
[1...M]
Patient
[1...P]
Rxb1
Healthcare
Services
[1..Hc]
Rx0
Doctor
[1 ...D]
Warren Doctor Case
Overview
•
A physician who practiced in Warren, Michigan, was sentenced to 84 months in prison today for writing prescriptions for
oxycodone and other controlled medications without medical justification, and for health care fraud.
Process
•
From 2010 through early 2012, the doctor conspired with, a patient “marketer,” and others, to write prescriptions for 80,000
oxycodone and Roxicodone, plus other controlled medications, in the names of people who were brought to him by the
marketer, as well as other marketers, for no medical purpose.
•
The marketers then bought the pills from the “patients” and re-sold them to street dealers.
•
The doctor then used the patient data for the patients brought to him by the marketers to submit bills to Medicare and Blue
CrossBlue Shield for services that were either never performed or were medically unjustified.
•
The doctor caused these same patients to receive monthly x-rays, and other invasive tests, which were medically
unnecessary but helped to conceal his fraud. The doctor admitted that he defrauded Medicare, Medicaid, and Blue Cross of
about $2.3 million.
Sentence
•
In addition to imprisonment, the doctor was ordered to pay restitution to Blue Cross and Medicare in the total amount of
$2.3million, and was ordered to forfeit various assets and agree to pay the government $2.3 million.
Societal Comments
•
The judge in the case said, "More people die from overdoses of prescription drugs in America than from overdoses of all
other drugs combined. We hope that prosecuting the doctors who are putting these drugs on the streets will deter others
from contributing to this epidemic.”
•
“The Drug Enforcement Administration has made it a priority to address the dangerous practice of illegally diverting
prescription medications. Prescription drugs, such as oxycodone and Roxicodone, are controlled substances for a very good
reason. If they are abused, they can lead to addiction, illness, or even death.
•
This physician violated the public trust by illegally diverting prescription drugs on to the streets. This sentence makes it clear
that the DEA, and our partners in law enforcement, will continue to utilize our investigative techniques to bring to justice
those individuals that are responsible for the illegal distribution of prescription medicines.”
•
https://www.justice.gov/usao-edmi/pr/warren-doctor-sentenced-unlawful-oxycodone-prescriptions-and-health-care-fraud
The 44 Case
Indictment
•
The 13-count superseding indictment charges 44 new defendants with a drug conspiracy involving prescription drug controlled
substances such as Oxycontin, Opana, Vicodin, and other drugs. Health care fraud charges were filed against 32 of the defendants,
while three defendants were charged with money laundering and three defendants were charged with being felons in possession
of firearms.
Process
•
The superseding indictment alleges that owners of home health agencies, would provide kickbacks, bribes, and other illegal
benefits to physicians to induce them to write prescriptions for patients with Medicare, Medicaid, and private insurance.
•
Patients were recruited into the scheme by patient recruiters or “marketers,” who would pay kickbacks and bribes to patients in
exchange for the patients’ permitting the pharmacies and physicians to bill their insurance for medications and services that were
medically unnecessary and/or never provided.
•
During this conspiracy, prescriptions were presented to the Sav-Max (pharmacist), Sav-Mart (pharmacist), Atrium (pharmacist and
manager), or Caremax (pharmacist and manager) Pharmacies for filling. The medical professionals and health care agency owners
would then bill the relevant insurers for services supposedly provided to the patients, without regard to the medical necessity of
those prescriptions and services.
•
Some of the pharmacists would bill insurers, including Medicare, Medicaid, and private insurers, for dispensing the medications,
despite the fact that the medications were medically unnecessary and, in many cases, never provided. Other times, the
pharmacists accepted cash from the recruiters for filling and dispensing medications.
•
The indictment further alleges a conspiracy to distribute controlled substances by the health care owners, physicians, pharmacies,
and recruiters to facilitate the submission of false claims to Medicare, Medicaid, and private insurers. The home health care
owners paid physicians associated with the scheme kickbacks in exchange for prescriptions for controlled substances for their
patients which were filled at the respective pharmacies. The controlled substances involved included the Schedule II drug
oxycodone (Oxycontin), the Schedule III drug hydrocodone (Vicodin, Lortab) the Schedule IV drug alprazolam (Xanax), and the
Schedule V drug cough syrup with codeine.
•
The indictment further alleges individual charges of felon in possession of a firearm against marketers and home health agency
owner. Also, illegal money laundering by pharmacists, and also by home health agency owner .
•
https://m.fbi.gov/#https://www.fbi.gov/detroit/press-releases/2013/forty-four-individuals-indicted-in-health-care-fraud-anddrug-distribution-scheme