By: Jeffrey S. Baird, Esq. Many pharmacies work with skilled nursing facilities (“SNFs”) and custodial care facilities (collectively referred to as “Facilities”). A Facility is a “referral source” to the pharmacy. Even though the Facility may give “patient choice,” if the pharmacy dispenses a drug to a Facility patient, the law considers the patient to […]
By: Jeffrey S. Baird, Esq. In a June 16, 2017 article in the Harvard Business Review entitled “Value-Based Care Alone Won’t Reduce Health Spending and Improve Patient Outcomes,” David J. Bailey, M.D. (President/CEO of Nemours Children’s Health System) stated: “Despite spending twice what other developed nations spend on a per capita basis for health care, […]
By: Jeffrey S. Baird, Esq. Generally, federal law prohibits health care providers from employing or contracting with individuals that are excluded from participation in federal health care programs (“Excluded Individuals”). Excluded Individuals can include persons convicted of crimes. Excluded Individuals While CMS does not prohibit a health care provider from ever hiring a convicted felon, […]
By: Jeffrey S. Baird, Esq. Introduction Historically, governmental regulatory agencies have not been overly aggressive in bringing enforcement actions against pharmacies under the Medicare anti-kickback statute, state anti-kickback statutes, and other anti-fraud laws. This is changing for a number of reasons. First, because pharmacies are billing a number of government health care programs (Medicare, Medicaid, […]
By: Jeffrey S. Baird, Esq. The U.S. Department of Justice (“DOJ”) and the Office of Inspector General (“OIG”) have become much more aggressive in bringing civil and criminal investigations against pharmacies and their owners. Many investigations are a result of qui tam (whistleblower) lawsuits. This is when a disgruntled ex-employee, disgruntled current employee, or any […]
By: Jeffrey S. Baird, Esq. There is an ongoing whistleblower case involving a pharmacy that reads like a law school exam. In a typical law school exam, a hypothetical set of facts are given and the student must pick out the legal issues and discuss them. Often, there are multiple legal issues that arise from […]
By: Jeffrey S. Baird, Esq. A Pharmacy Benefit Manager, also known as a PBM, is a third party administrator contracted by health plans, employers, unions and government entities to manage prescription drug programs. A PBM acts as a fiscal intermediary between insurers/payors and pharmacies. There is an old saying: “Possession is 9/10ths of the law.” […]
