US Industry Warned Over Reimbursement Fraud

Increased funding to prevent fraud and abuse in the US health carereimbursement system will mean increased scrutiny in all areas, including drugs, Kevin McAnaney, chief of the Industry Guidance Branch at Health and Human Services' Office of Counsel to the Inspector General, told the US Food and Drug Law Institute's Pharmaceutical Update meeting (Marketletter June 2).

Higher enrollment of Medicare beneficiaries in Health Maintenance Organization plans with a prescription drug benefit will mean more scrutiny of the drug sector; previously, drug reimbursements for Medicare/Medicaid beneficiaries were few. He warned against using coupons offering rebates, even with the proviso that they should not be used in Medicare/Medicaid programs. Services of any kind will be classed as remuneration, and if the company is offering services, this is seen as double-dipping. Discounts based on volume are understandable, but other rebates are often just an inducement to shift patients to another product. A company compliance policy must be put in place, enforced, and followed through by commitment from top management, or it could become a detriment to the company.

Health care fraud prosecution is a top priority at the Justice Department, said Michael Theis, assistant US attorney at Justice in Colorado. The False Claims Act offers treble damages and per claim civil penalties of $5,000 and $10,000, and it is flexible, extending liability to those who "cause" false claims to be presented or "conspire" to get them allowed or paid. A company compliance program offers benefits, he said; it is not a "get out of jail free" card, but will be taken into account when Justice decides which cases to investigate and prosecute, penalties to assess and if grievances can be resolved.