Do you ever have trouble reading the scribbled name of the drugs your doctor writes on a prescription? Sometimes I wonder if the pharmacist ever gets it wrong. Well, the answer is yes, but not in the way you might expect. Some pharmacies intentionally substitute drugs – if it means they make more money! It happens more often than you might like to think.
CVS Caremark Corp (aka CVS), is the largest pharmacy chain in the country, with more than 6,000 stores. It fills millions of prescriptions each year. Based on that volume, when it found a way to make money by switching drugs, the temptation was too great to resist.
When it discovered a loophole in the Medicare system, CVS succumbed to greed.
Medicare paid CVS a maximum of $17.10 for 60 tablets of Ranitidine, the generic version of Zantac. However, Medicare did not establish a maximum for capsules of the same drug, because it was so rare for capsules of that drug to be prescribed by doctors. Although there is no medical difference, patients prefer tablets for Ranitidine.
CVS was only too happy to game the system. It insisted that its pharmacies stock Ranitidine capsules, not tablets. So whenever a prescription arrived for 60 tablets of Ranitidine, the CVS pharmacists had no choice but to substitute capsules. CVS then charged Medicaid $79.80 for 60 capsules – more than 4 times the amount it could have charged if it had followed the prescription and given patients tablets. The switch went unnoticed by Medicare because no limit had been set for capsules.
Luckily, a part-time pharmacist at one of the CVS pharmacies did notice. He wondered why the store never carried tablets and always switched to capsules. After a little checking, he soon realized that CVS was scamming Medicaid. He hired an attorney to help him report the fraud to the Department of Justice under its Whistleblower Reward Program.
After a nationwide investigation was conducted, the government required CVS to repay $36.7 million in overpayments due to the switching of this one drug. The part-time pharmacist received $4.3 million from the government as his reward for blowing the whistle on this fraud.
This is not the first time a company has switched drugs to swindle Medicaid. In 2006, Omnicare Inc., which has long-term care facilities in 47 states, switched several drugs, including Ranitidine and Buspar, a generic form of Prozac. Omnicare changed prescriptions for a single 15 mg tablet of Buspar to two 7.5 mg tablets because it could bill more for two smaller dosages of the same drug. Omnicare settled the fraud allegations by paying $50 million. The whistleblower received $5.3 million.
If you know of a pharmacy, nursing home, or any other entity that is switching drugs to bilk Medicaid, do the right thing by stepping forward. There may be substantial financial rewards, but the rewards will also include making health care more affordable and ensuring that what the doctor prescribes is what patients get! We may not be able to read our prescriptions, but we definitely want to be sure we're getting what the doctor ordered.
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