Costly Cure

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42947095 - prescription form lying on table with stethoscope, pen and pile of pills fell out from jar. medicine or pharmacy concept. tablets and recipe.

Hepatitis C is a dangerous disease because people who have it can be infected for 30 or more years and not even know it. (Here’s a scary statistic – according to the Centers for Disease Control and Prevention (CDC), approximately 2.7 million people in the United States have chronic hepatitis C.) The viral infection damages the liver over time and a chronic infection can lead to cirrhosis, liver cancer and even liver failure. Thanks to new treatment advances, Hepatitis C can be cured with costly new medicines. These revolutionary drugs lead us to today’s Medicaid fraud case which was committed by a former clinical pharmacy manager in Tennessee.

The former pharmacy manager from Jonesborough illegally enabled TennCare (Tennessee’s Medicaid Program) beneficiaries to receive prescriptions for expensive drugs used to treat Hepatitis C. (The problem with this is that TennCare has some explicit rules when it comes to doling out drugs to treat this disease. If the patient abuses illicit substances or has limited or no scarring of the liver, they are not eligible.)

Over one-and-a-half years, the pharmacy manager falsified prior authorizations, medical lab reports, and drug test results for at least 51 Hepatitis C patients so they could receive the costly medicine. (Patient lab reports and drug tests show that they failed to meet TennCare eligibility requirements.) In addition, she made up allergies for some of the patients so they could qualify to receive the most expensive drug. In all, $4.4 million was paid by TennCare so approximately 51 patients could purchase the more expensive Hepatitis C drug. (That averages out to about $86,274.51 for each patient. Wow, that is outrageously expensive!)

The 33-year-old fraudulent pharmacy manager was sentenced to 16 months in federal prison for committing healthcare fraud. After finishing out her prison term, she’ll be on probation for three years.

There’s no motive mentioned behind today’s fraud by the former clinical pharmacy manager from Jonesborough, Tennessee, but perhaps she was trying to help her clients to receive better care. Or, maybe she benefited in some way from the number of prescriptions she issued for a particular drug. No matter how you look at it, she disobeyed government regulations and falsified patient information so that they could receive a costlier drug. In the end, it is the taxpayers that ultimately had to foot the bill for this particular Medicaid fraud scheme, a costly illness that also desperately needs a cure.

Today’s “Fraud of the Day” is based on an article entitled, Former clinical pharmacy manager sentenced for TennCare fraudposted on WCYB.com on June 26, 2017.

A former clinical pharmacy manager from Jonesborough was sentenced to 16 months in federal prison Monday for healthcare fraud, which resulted in at least a $4.4 million loss to TennCare.

Upon 33-year-old Amber Reilly’s release from prison, she will be on probation for three years. Reilly pleaded guilty in October 2016 to one count of healthcare fraud. In her plea agreement, she admitted that between October 2014 and April 2016, she falsified prior authorizations, medical lab reports, and drug test results for at least 51 Hepatitis C patients who had prescriptions for expensive drugs used to treat Hepatitis C.

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Larry Benson, Senior Director of Strategic Alliances, LexisNexis Risk Solutions - Government

Larry Benson is responsible for developing strategic partnerships and solutions for the government vertical. His expertise focuses on how government programs are defrauded by criminal groups, and the approaches necessary to prevent them from succeeding.

Mr. Benson has 30 years of experience in sales and business development. Before joining LexisNexis® Risk Solutions, he spent 12 years founding and managing two software technology startups. During the 1990s he spent 10 years as a Regional Director helping to grow a New England-based technology company from 300 employees to 7,000. He started his career with Martin Marietta Aerospace working on laser guided weapons and day/night vision systems.

A sought-after speaker and accomplished writer, Mr. Benson is the principal author of “Fraud of the Day,” a website dedicated to educating government officials about how criminals are defrauding government programs. He has co-authored WTF? Where’s the Fraud? How to Unmask and Stop Identity Fraud’s Drain on Our Government, and Data Personified, How Fraud is Changing the Meaning of Identity.

Benson holds a Bachelor of Science in Physics from Albright College, and earned two graduate degrees – a Master of Business Administration from Florida Institute of Technology, and a Master of Science in Engineering from Lehigh University.