A case from North Carolina highlights what we see too often: healthcare entrepreneurs and providers committing fraud, paying monetary penalties and even facing incarceration. But rarely do we see the penalties travel down the ladder to a company’s employees. A pharmacy owner was sentenced to 24 months this month for conspiracy to commit fraud. Apparently, the pharmacy owner ran a scheme for 11 years, billing Medicare, Medicaid and private insurers for prescription drugs that were never dispensed. Sadly, if you read enough of these OIG reports, billing for services that were not rendered is not new, and sooner or later, the authorities catch up to these criminals.
The interesting twist is that one of the pharmacist’s former employees was also sentenced to 24 months imprisonment, followed by three years of supervised release, in connection with the same scheme. It was uncovered that the pharmacy owner trained the employee and other workers on how to bill insurance plans for drugs that were not authorized, how to falsely reauthorize a previously existing prescription from a licensed medical professional, and how to falsely bill health care benefit programs as though a drug had been dispensed. The OIG’s press release summed the case up by reporting that the employee began independently running the pharmacy while the owner knowingly profited from the fraudulent billing practices!
The takeaway for employees from this case is: “Just following orders” isn’t a defense. Anyone working in healthcare for even a day should have the basic understanding that billing for a product or service that was not provided is against the law, as well as a personal line in the sand which she will not cross. What went through that employee’s mind the first time someone trained her to bill a false claim or resurrect an old prescription? In that split second, with the alarm bell subtly ringing in her mind, she made a choice. In this case, it was the wrong one.