Be the Whistleblower
to Shine a Light
on PBM Fraud
We are a dedicated team of legal professionals specializing in False Claims Act cases, particularly those involving Pharmacy Benefit Managers (PBMs).
If you suspect fraudulent activities within the operations of a PBM, our experienced attorneys are here to help guide you through the process of becoming a whistleblower.
Be the Whistleblower
to Shine a Light
on PBM Fraud
We are a dedicated team of legal professionals specializing in False Claims Act cases, particularly those involving Pharmacy Benefit Managers (PBMs).
If you suspect fraudulent activities within the operations of a PBM, our experienced attorneys are here to help guide you through the process of becoming a whistleblower.
Pharmacy Benefit Managers & Qui Tam Fraud
Pharmacy Benefit Managers (PBMs) play a crucial role in administering prescription drug benefits for health insurance plans, but they can also become involved in practices that may lead to qui tam lawsuits under the False Claims Act (FCA). Qui tam lawsuits allow private individuals, known as “relators” or “whistleblowers,” to sue on behalf of the government and potentially share in any recovery.
Whistleblowers can receive a share of the recovered funds as a reward for their efforts in exposing the fraud, which can be between 15% and 30% of the total recovery.
Types of PBM Fraud
Fraud and abuse within PBM operations can take various forms, including:
PBMs might be involved in spread pricing where they charge health plans a higher price for medications than the amount they reimburse pharmacies, keeping the difference as profit. If the PBM does not transparently disclose these practices to their clients, especially government-funded programs, this could potentially constitute a false claim.
Under the Anti-Kickback Statute, which is closely related to the FCA, PBMs could face liability for receiving or giving anything of value to influence the referral of federal healthcare program business. Engaging in such practices could trigger qui tam lawsuits.
PBMs often negotiate rebates from pharmaceutical manufacturers. There might be issues if PBMs fail to accurately report or pass these rebates onto the health plans, especially those serving government programs like Medicaid, leading to allegations of false claims or misrepresentations.
Common PBM Practices and Concerns
PBMs employ various practices to manage prescription drug benefits, including:
PBMs decide which drugs are covered and at what tier, influencing medication choices and costs.
PBMs contract with pharmacies to create networks that provide prescription services to their members.
PBMs negotiate rebates with drug manufacturers in exchange for favorable formulary placement.
While these practices can help manage costs, they also raise concerns about transparency, conflicts of interest, and the potential for PBMs to prioritize their own profits over patient care and cost-effectiveness.
Whistleblower Protections
The False Claims Act provides strong whistleblower protections to encourage individuals to come forward without fear of retaliation. As a whistleblower, you are safeguarded against any form of employment retaliation, including dismissal, demotion, suspension, threats, harassment, or any other form of discrimination.
Whistleblower Rewards
Whistleblowers play a crucial role in uncovering fraud against government programs, and the law recognizes this by offering financial incentives. If your information leads to a successful recovery of funds, you may be entitled to a percentage of the recovered amount, typically between 15% and 30% of the total recovery.
How to Document Your Case
Gathering substantial evidence is key to building a strong qui tam case. Document all relevant communications, transactions, and other information you believe demonstrate fraudulent behavior. Keep detailed records, including dates, names involved, and descriptions of incidents. Our legal team will help you organize and present your findings effectively.
CONTACT US
If you believe you have witnessed fraudulent activities by a PBM, don’t hesitate to contact us.
Our skilled and experienced attorneys are ready to assist you every step of the way.
Together, we can work towards exposing fraud and achieving justice.
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