Caremark Whistleblower Gets $1 Million in False Claims Case By Tod Aronovitz | 10/02/14 | 0 Comment

Caremark LLC, a pharmacy benefit management company (PBM) operated by CVS Caremark Corporation, has agreed to pay the United States $6 million to resolve allegations that it failed to properly reimburse Medicaid for beneficiaries receiving dual prescription drug benefits under both a Caremark-administered plan and Medicaid, according to a Justice Department announcement.

In the case where individuals are “dual eligible”—or covered by both Medicaid and a private health plan—the private insurer must cover the costs of health care rather than the government. Under current law, if Medicaid mistakenly pays the prescription claim of a dual eligible, it may seek reimbursement from the private insurer or its PBM. A PBM administers and manages the drug benefits for clients who offer drug benefits under a health insurance plan.

The allegations settled by Caremark stemmed from a lawsuit filed by Caremark whistleblower and former employee Donald Well under the qui tam or whistleblower provisions of the False Claims Act. Well will receive $1.02 million plus interest as a result of the Act’s provisions, which allowed him to sue on behalf of the government for false claims and share in any recovery.

The United States may also intervene in a whistleblower lawsuit, as it did here. According to the government, Caremark’s computer platform, “RxCLAIM,” incorrectly subtracted certain co-payment or deductible amounts when calculating payments. Therefore, the full amounts due on certain claims were not paid. The government alleged that Caremark’s deliberate actions caused Medicaid to process prescription drug costs when Caremark-administered private health plans should have paid for them instead.

“It is vitally important that cash-strapped Medicaid programs receive reimbursement for the costs they incur that should properly have been paid for by other insurers,” said Acting Assistant Attorney General Joyce R. Branda for the Justice Department’s Civil Division. “We are committed to protecting the integrity of state Medicaid programs.”

The Caremark whistleblower case was jointly handled by the U.S. Attorney’s Office for the Western District of Texas, the Justice Department’s Civil Division, and the Department of Health and Human Services Office of Inspector General, and is captioned United States ex rel. Well v. CVS Caremark, Inc., Civil Action No. SA:11-CV-00747 (W.D. Tex.).

How to Report Miami Medicare Fraud

Healthcare professionals or medical billing employees who have knowledge of questionable Medicare billing practices can file a confidential legal claim under the False Claims Act. By acting as a “whistleblower” in what is known as a “qui tam” lawsuit, a private party may collect up to 30 percent of the amount recovered, depending on how the case is prosecuted.

ARONOVITZ LAW: Miami Whistleblower / Qui Tam Law Firm

The Miami Qui Tam law firm of ARONOVITZ LAW routinely works with whistleblowers to document Medicare fraud and other forms of fraud against the government. Contact Miami Whistleblower / Qui Tam lawyer Tod Aronovitz to discuss your case.