Have You Witnessed Medicaid Fraud?
Contact the Medicaid Whistleblower Attorneys at Nolan, Auerbach & White to get started on a free and 100% confidential review of your important case. Call our Whistleblower Healthcare Fraud Attorneys at 800.372.8304 today.
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Protecting The Medicaid Fraud Whistleblower
The purpose of the Qui Tam provisions of the FCA is to encourage private individuals aware of Medicaid Fraud and Abuse to bring such information forward under a confidential and protected status. Our experienced team of Medicaid Fraud Lawyers at The Whistleblower Firm can advise you of your options and expectations. Begin this important duty and service by scheduling a free review of your case.
For many Medicaid Fraud Whistleblowers, it is possible to collect a percentage of what has been recovered as an award for this vital service. CMS Whistleblower rewards for Medicaid vary from 15-30 percent of the amount collected.
LEARN MORE: Whistleblower Protection
Identifying Medicaid Fraud and Abuse
Fraudulent activity with Medicaid typically coincides with a violation of the False Claims Act. When you’re ready to explore your options as a potential whistleblower, our Medicaid Fraud Lawyers are here to confidentially discuss the details of your important case.
Medicaid Billing Fraud and the Problem of Incomplete Data
Because spending for the Medicaid program is projected to exceed $900 billion by fiscal year 2025, reducing Medicaid Fraud will save consequential taxpayer dollars. One of the biggest issues facing the Medicaid program is a lack of timely, accurate, and complete data on the front end, before payment to healthcare providers. The work and oversight function of the Centers for Medicare and Medicaid Services (CMS) and its contractors are hampered in a “pay and chase” system when reimbursements are made to healthcare providers without any opportunity (other than edits) to ensure medical necessity, services actually delivered, appropriate coding, etc.
Our Medicaid Fraud Attorneys at The Whistleblower Firm are ready to confidentially discuss your case, along with potential CMS whistleblower rewards (via federal and state qui tam lawsuits ) involved in Medicaid Fraud Lawsuits. Find out your options by calling us or filling out our online form.
LEARN MORE: Medicaid Fraud Oversight Issues
Medicaid Drug Rebate Program
The Medicaid Rebate Program is one example of Medicaid Fraud. The scenario begins as a beneficiary obtains a prescription drug from a participating pharmacy, which has purchased the drug in the marketplace from a manufacturer or wholesaler. The pharmacist submits a claim and then receives payment from the state Medicaid agency based on the state’s formula for typically (Average Wholesale Price) AWP less a percentage.
The manufacturer then pays a rebate, each quarter, for all of its drugs reimbursed by Medicaid each quarter. In order to decrease the amounts owed to the states, some pharmaceutical companies misrepresent material facts in their quarterly submissions to the Medicaid Rebate Program reporting, to include misrepresentation of the regulatory origin/status of their Brand Name Drugs, the Average Manufacturer Price (AMP), and/or the Best Price.
The rebate for drugs is based in part on two prices submitted by the manufacturer to CMS each calendar quarter:
- Average Manufacturer Price (AMP) – the average price that a drugmaker receives in a given quarter for sales to wholesalers of a drug distributed in the retail class of trade.
- Lowest Transaction Price or “Best Price” – charged to any buyer in the private market (and reflecting all rebates or discounts) during that quarter.
Responsibilities of Medicaid Beneficiaries
The AMP and the Best Price must be reported for each respective dosage form and strength of all prescription drugs purchased on behalf of Medicaid beneficiaries. Those prices, which remain confidential, serve as reference points in determining drugmakers’ rebate obligations.
CMS calculates the unit rebate amount (URA) for each covered drug using price data submitted by the drug manufacturers. Each quarter, each State Agency sends an invoice to each drug manufacturer/labeler, using the URA from CMS and the units dispensed for each drug (from its own records), to determine the actual rebate amounts due from the manufacturer. The manufacturer has 38 days from the day a State Agency sends an invoice to pay the rebate and avoid interest charges.
The Three Drug Categories for Rebates
In order to determine rebate amounts, the reporting requirements include designation of a drug’s status into one of three categories:
- “Innovator Multiple Source Drug” is defined by statute as having “the meaning set forth in Section 1927(k)(7)(A)(ii) of the Act and shall include all Covered Outpatient Drugs approved under a New Drug Application (NDA), Product License Approval (PLA), Establishment License Approval (ELA) or Antibiotic Drug Approval (ADA). A Covered Outpatient Drug marketed by a cross-licensed producer or distributor under the approved NDA shall be included as an innovator multiple source drug when the drug product meets this definition.” 42 U.S.C. § 1396r-8(c)(1)(C)(k). In 42 CFR 447.502, CMS clarified that an Innovator Multiple Source type of drug includes an authorized generic drug including any labelers operating under the NDA.
- “Single Source Drug” is defined by statute as “a covered outpatient drug which is produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the New Drug Application (NDA).” It also includes a Covered Outpatient Drug approved under a PLA, ELA or ADA.
- “Non-Innovator Multiple Source Drug” is defined by statute as “a multiple source drug that is not an innovator multiple source drug.”
A Single Source, and an Innovator Multiple Source Drug, are both commonly known and referred to herein as a “Brand Name Drug,” while a Non-Innovator Multiple Source Drug is commonly known as, and referred to herein as a “Generic Drug.”
CMS Rebate Formula for Drugs
For Brand Name drugs, the rebate consists of two components:
- The manufacturer must pay a “basic rebate” equal to the greater of (i) 15.1 percent of the “Average Manufacturer Price” (AMP) of the drug or (ii) the difference between the drug’s AMP and its “Best Price” (BP) whichever is greater; plus
- The manufacturer must pay an “additional” rebate to the extent that the AMP of the drug has increased faster than the rate of inflation since the launch of the product.
The manufacturers of Brand Name Drugs almost always owe the additional rebate. In 2003, for instance, the drugs for which an additional rebate was owed represented about 84 percent of Medicaid’s reimbursements for brand-name prescription drugs. In its report, “The Rebate Medicaid receives as Brand-Name Prescription Drugs” dated June 21, 2005, the Congressional Budget Office of the United States, estimated that in 2003, the average rebate received by Medicaid for brand-name prescription drugs was 31.4% of the AMP.
The rebate for Generic Drugs is much less than for Brand Name Drugs. It is a base rate of 11% of AMP, with no additional rebate. In contrast, the total rebates due for Brand Name Drugs have typically been within a couple of points of 31% of AMP, a difference of roughly twenty (20) percent.
Our Medicaid Fraud Lawyers can help clarify whether or not fraud exists in each scenario. Contact us for a free and 100% confidential case review.
Medicaid Fraud Lawsuits and Other Cases We Handle
Our law firm representing whistleblowers has the experience to discuss in-depth areas of Healthcare Fraud. Our Medicaid Fraud Attorneys are advocates for many CMS whistleblowing clients and those exposing other fraud that may include:
Explore your options as a CMS whistleblower by filling out our confidential online form for potential clients or give Nolan, Auerbach, and White and our experienced team of Qui Tam Medicaid Fraud Attorneys a call today at 800.372.8304.
CONTACT THE WHISTLEBLOWER FIRM
Does your case have merit? We invite you to confidentially submit your facts to our experienced Medicaid Fraud Lawyers for a free case evaluation.
Join the many whistleblower heroes we have represented. We’re here to help you take the next courageous step forward by doing the right thing and pursuing justice. We understand the pressure of becoming aware of significant fraud, and we are here to alleviate that pressure and turn a negative situation at work into a positive outcome for you.
You are protected by law against retaliation and whistleblowers can receive a percentage of the funds recovered from the Defendant under the FCA.
Get started by filling out our online form, or call our team of experienced Medicaid Fraud Lawyers at 800.372.8304.
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Frequently Asked Questions About Medicaid Fraud Lawsuits
✅ What Kinds of CMS Whistleblower Rewards Exist for Exposing Medicaid Fraud?
Eligible whistleblowers may receive between 15-30 percent of the amount collected in Medicaid Fraud cases, through the qui tam provisions of federal and state statutes. To learn more about the potential of your knowledge, obtain quick feedback, and learn what we can do for you, begin a free evaluation of your important case.
✅ What Percentage of False Claims Act Cases Are Successful?
The National Conference of State Legislatures notes that “about 80 percent of all fraud cases won under the FCA are a direct result of whistleblower lawsuits.” If you are aware of Medicaid fraud, contact our Healthcare Fraud Law Firm to confidentially discuss more with a Medicaid Fraud Attorney.