Pharmacy Claims Whistleblower

Whistleblower Lawyers for Pharmacy Employees and Others Who Need to Report Fraudulent Claims

Like all healthcare entities that bill Medicare, pharmacies are subject to numerous billing restrictions under federal law. Pharmacies must strictly—and consistently—comply with these restrictions; and, when they fail to do so, they have an obligation to “report and return” improper payments to the Centers for Medicare and Medicaid Services (CMS) or their Part D sponsor.

Unfortunately, pharmacies don’t always comply with the law. Pharmacy fraud involving expensive drugs costs taxpayers billions of dollars per year by targeting federal health care programs; and, in many cases, it harms patients as well. While federal agencies including the Federal Bureau of Investigation (FBI) and U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG) investigate pharmacy fraud, they also rely heavily on whistleblowers to inform them when investigations are warranted.

Are you eligible to serve as a pharmacy claims whistleblower?

If you are aware of a pharmacy submitting improper claims for Medicare reimbursement–such as charging for a brand-name when dispensing a generic drug–and/or failing to “report and return” improper payments, you may be able to help the federal government take action. You may also be eligible to receive a whistleblower reward. Reporting pharmacy fraud generally involves coming forward under the False Claims Act (FCA), and the FCA includes provisions for whistleblower compensation in appropriate cases.

When Can (and Should) You Serve as a Pharmacy Claims Whistleblower?

Employees of retail pharmacies and compounding pharmacies (both current and former) and other individuals can report a wide range of claim-related violations to the federal government. If you believe that you have access to any non-public information about a pharmacy improperly billing Medicare, whether directly or through a Part D sponsor, we strongly encourage you to schedule a free and confidential consultation at Oberheiden P.C. Some examples of the types of violations that our pharmacy claims whistleblower lawyers may be able to help you report include:

• Failing to submit “clean claims” for drug coverage reimbursement under the Medicare Part D program to a Part D sponsor
• Generating false documentation to make fraudulent claims appear to be “clean claims”
• Failing to report Medicare overpayments to CMS or a Part D sponsor
• Improperly delaying reporting of overpayments based on a sham “good-faith” investigation
• Attempting to cover up Medicare overpayments 
• Knowingly submitting false claims for Medicare reimbursement 
• Billing Medicare for ineligible prescription drugs provided to non-patients (including medications diverted for unauthorized use)
• Non-compliance with pharmacies’ federal recordkeeping requirements (including those related to drug ordering, storage of controlled substances, and electronic prescriptions)
• Soliciting or accepting kickbacks in exchange for referring Medicare beneficiaries to healthcare providers 
• Offering or paying kickbacks to healthcare providers in exchange for having them write prescriptions for a particular drug for Medicare beneficiaries

Again, these are just examples. Improper pharmacy claims practices can take many different forms, and they can lead to criminal and civil liability at all stages of the claim lifecycle. Once again, if you have any reason to suspect that a pharmacy has improperly billed Medicare–whether directly or through pharmacy benefit managers–we strongly encourage you to speak with one of our lawyers about serving as a pharmacy claims whistleblower.

When you speak with a lawyer at our firm about coming forward, your lawyer will explain everything you need to know about working with government agencies in order to make an informed decision. Scheduling a free consultation does not obligate you to blow the whistle, but it can help you understand how your report may impact patient safety and federal enforcement efforts. Some examples of the types of considerations your lawyer will discuss with you include:

• False Claims Act Whistleblower Eligibility Generally – Not everyone is eligible to serve as a whistleblower under the False Claims Act. In addition to having access to non-public information about pharmacy fraud, whistleblowers must also generally be the first to come forward, and they must meet various other requirements as well. With that said, many individuals who have access to non-public information about fraudulent pharmacy billings under Medicare will qualify. 
• Your Specific Eligibility to Serve as a Pharmacy Claims Whistleblower – Along with discussing the general whistleblower eligibility criteria under the FCA, your attorney will also provide a preliminary assessment of your specific eligibility. While additional information may be necessary, your attorney can walk you step-by-step through the process of determining (and documenting) your eligibility for protected whistleblower status. 
• The Protections Afforded to Whistleblowers Under the FCA – Pharmacy claims whistleblowers who come forward under the FCA are entitled to strong protections under federal law. These include confidentiality protections and protections against retaliation for exposing fraudulent practices within a pharmacy. Your lawyer will go over these protections in detail so that you can factor them into your decision-making. 
• The Compensation Awarded to Whistleblowers Under the FCA – As discussed above, the FCA includes provisions for whistleblower compensation in appropriate cases, including those involving false claims related to how a manufacturer’s drug was billed or dispensed. If you are interested in seeking a whistleblower reward, your lawyer will provide a preliminary assessment of your eligibility and discuss the factors that go into determining whistleblower rewards. 
• The Process of Serving as a Pharmacy Claims Whistleblower Under the FCA – Serving as a pharmacy claims whistleblower under the FCA is a unique process, especially in matters involving certain drugs subject to Medicare restrictions or improperly billed for off-label use. Under the FCA, whistleblowers must file a qui tam lawsuit in federal court, and they must be prepared to work with federal agents and prosecutors while they work to resolve allegations contained in whistleblowers’ qui tam complaints. Here too, your lawyer can walk you step-by-step through the process so that you can make informed decisions, including how to proceed if your case involves a new drug not approved for reimbursement.

Once again, these are just examples. When deciding whether to serve as a federal whistleblower, it is critical to ensure that you are making an informed decision based on a clear understanding of everything you need to know. As both experienced federal whistleblower lawyers and former federal healthcare fraud prosecutors, we are intimately familiar with the federal whistleblower procedures, and we can provide you with a detailed understanding of what you can expect if you decide to come forward.

Put our highly experienced team on your side

Dr. Nick Oberheiden

Founder

Attorney-at-Law

Lynette S. Byrd

Former DOJ Trial Attorney

Partner

Brian J. Kuester

Former U.S. Attorney

Hon. Kevin McCarthy

55th Speaker, U.S. House of Representatives (ret.)

Government Consultant

Mike Pompeo

Of Counsel

Former U.S. Secretary of State

John W. Sellers

Former Senior DOJ Trial Attorney

Linda Julin McNamara

Federal Appeals Attorney

Nicholas B. Johnson

Former Prosecutor

Roger Bach

Former Special Agent (DOJ)

Chris J. Quick

Former Special Agent (FBI & IRS-CI)

Michael S. Koslow

Former Supervisory Special Agent (DOD-OIG)

Ray Yuen

Former Supervisory Special Agent (FBI)

Working with a Pharmacy Claims Whistleblower Lawyer at Oberheiden P.C.

During your free initial consultation, your whistleblower lawyer will also go over what you can expect as a client of Oberheiden P.C. This includes discussing our approach to maintaining strict confidentiality throughout the process, as well as our contingency-fee representation for pharmacy claim whistleblowers who come forward under the False Claims Act. In short, we will not disclose any information you share with us unless you explicitly authorize us to do so, and you will not have to pay anything out-of-pocket for our legal services.

FAQs: Serving as a Pharmacy Claims Whistleblower Under the False Claims Act