Walking a Fine, Wavy Line

36404377 - pharmacist writing on clipboard and holding medicine jar at the hospital pharmacy

For a Carl Junction, Missouri pharmacist, there’s a fine, wavy line between legally and illegally filling prescriptions. Today’s fraudster committed healthcare fraud by signing for auto-refill prescriptions that were intended for his pharmacy’s clients and billing Medicare, Medicaid and Tricare for refills that were never picked up.

The pharmacist, who co-owned the Missouri pharmacy with a pharmaceutical company located in Oklahoma, carried out his fraud scheme over more than five-and-a-half years. Pharmacy customers who were registered to receive automatic prescription refills were his victims. (As you might guess, many of his customers were unaware that their prescriptions were being automatically refilled, therefore, they never picked them up.)

The automatic prescription refills were placed in a pickup drawer. After the pharmacy would close for the evening, employees noticed that these prescriptions were missing the following morning. (Obviously, if the pharmacy was closed, how could patients pick up their prescriptions? Most definitely not a legitimate way to boost revenue.) And, because the pharmacist was the only one that could access the pharmacy’s computer system, he adjusted the register to zero indicating that the co-pay had been received (the prescription was picked up) and the rest of the tab would be billed to insurance providers, including Medicare, Medicaid and Tricare.

Pharmacy employees rebelled against their leader’s crime by notifying the Department of Health and Human Services. Following an audit of the pharmacy’s prescription program, “significant irregularities” were discovered. (Apparently, auditors found that some customer signatures were missing even if the prescription was reported as being received. Others had wavy lines instead of patient signatures.) Once the irregularities were discovered, the pharmacy’s co-owner was notified, and they launched another investigation, which found even more issues.

The 62-year-old man from Missouri caused approximately $115,246 in claims to be paid. Court documents show that nearly $60,000 in losses were incurred by multiple health care benefits programs. As a result of walking the fine, wavy line between legally and illegally operating his pharmacy, the pharmacist pleaded guilty to healthcare fraud. Because he crossed the line, he is now required to walk a straight line by paying $59,246 in restitution and serving five years of probation.

Today’s “Fraud of the Day” is based on an article entitled, “Carl Junction pharmacist pleads guilty to health care fraud,” published by The Joplin Globe on July 24, 2018.

CARL JUNCTION, Mo. — A Carl Junction pharmacist pleaded guilty Monday in federal court to health care fraud in the submission of false Medicare, Medicaid and Tricare claims.

Jerry Eugene Botts, 62, entered the plea in U.S. District Court in Springfield in a plea agreement calling for surrender of his pharmacist license, $59,246 in restitution to various health care benefits programs and five years of probation.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.