Medicaid Policies and Procedures

Does your specialty pharmacy or pharmacy practice deal with Medicaid claims? If so, you had better take note of some breaking news that was just released by the New York State’s Attorney late last week. New York announced that the state has entered into a settlement agreement with CareMed Pharmaceutical services for almost $850,000 due to allegations of Medicaid fraud by the company. The New York based specialty pharmacy doing business in the state under the DBA Sorkins’ Ltd. Rx was accused of submitting false statements to the New York State Medicaid Program to secure expeditious prior authorizations for the coverage of specialty drugs. It also was accused of submitting false claims to the New York State Medicaid Program for certain prescription medications that were restocked and resold and for refills that recipients never obtained. As part of the settlement agreement, Sorkin’s admitted to the following conduct during the period of January 1, 2009, through December 31, 2012:

  • When contacting insurance companies to obtain prior authorization for coverage of specialty drugs prescribed for Medicaid recipients, some representatives of Sorkin’s falsely stated they were calling from the prescribing physician’s office. In some instances, Sorkin’s representatives responded to questions seeking clinical information based on their understanding of the prior authorization criteria for the particular drug, instead of obtaining patients’ actual clinical information from prescribing physicians and conveying that information.
  • Sorkin’s failed to adequately oversee and train staff responsible for the prior authorization process.
  • Sorkin’s had inadequate procedures and auditing processes in place to ensure that some claims submitted to certain third-party payors for Rituxan and Procrit, including claims for payment to Medicaid and Medicare Part D, were reversed when necessary or credited to the Medicaid or Medicare Part D plans after Procrit and Rituxan were returned to the pharmacy and restocked, or not delivered to and/or received by the recipient.

The point is that all pharmacies need to have Medicaid policies and procedures in place to handle such situations. Does your pharmacy have them? If the answer is no then we strongly urge you to contact HCC today to get the process started. Healthcare Consultants has over 25 years experience in Pharmacy Consulting and has been assisting retail, hospital, specialty and compounding pharmacies establish the necessary procedures and policies to deal with such situations should they arise. This is a definite example of the old cliche “an ounce of prevention is worth a pound of cure” being important for your pharmacy business. Call us today at  800-642-1652 for a free consultation with one of our in-house experts to see how HCC can make sure your pharmacy business is prepared for any emergency.

Bob Miller
10/15/2014


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