As prescription drugs – particularly expensive specialty drugs – have become an increasingly larger portion of health care costs in America, both private and public health insurers use co-pays and co-insurance to put cost constraints on prescription reimbursement. Concerned with market share and profit, drug companies regularly seek to circumvent these restrictions with tools such as Patient Assistance Programs or PAPs.
Why are Patient Assistance Programs a Problem for Medicare and Medicaid?
Public health insurance programs like Medicare and Medicaid care for elderly and low-income patients whose lives literally may depend on them. To ensure that taxpayer dollars are used as effectively as possible, Medicare and Medicaid programs require that the treatments they pay for are medically necessary, the most effective, with the fewest side effects and the least expensive. These include drug programs with prior authorization and step edit requirements, as well as prohibitions against offering kickbacks or other incentives to formulary committees, health care providers, patients or middlemen such as pharmacy benefit managers.
While they claim to be altruistic, Patient Assistance Programs are all too frequently used to bypass such controls, enlisting health care providers, middlemen and patients in an effort to pass along higher reimbursement costs to taxpayers.
Blow the Whistle If You See This Abuse!
Increased prosecution of fraudulent retail prescription drug reimbursements from public health insurance programs has caused many drug companies to shift their profit maximization focus to more expensive specialty drugs and the use of third-party Patient Assistance Programs. Federal and state governments have responded by putting additional scrutiny on PAPs that target Medicare and Medicaid patients. Prosecutors rely heavily on internal whistleblowers who can provide inside information to lay out the blueprint of the scheme.
If you are aware of a Patient Assistance Program (PAP) that is potentially defrauding public insurance programs, you may qualify to serve as a whistleblower. If the federal or a state government successfully prosecutes the allegations you bring to light, you may be entitled to a monetary reward.
With over 30 years of experience, the attorneys on Baron & Budd’s whistleblower representation team have represented dozens of clients in government fraud cases returning over $5.4 billion to federal and state agencies, with whistleblower recovery shares as high as 49%. They are ready to help if you have evidence of fraud involving patient assistance programs.
Please call (866) 401-5971 or complete our contact form if you would like more information. For more information, see What You Need to Know About Becoming a Whistleblower. Please understand that contacting us does not mean that you have established an attorney-client relationship with Baron & Budd, P.C.