15.7 Corporate Ethics/Medical Identity Theft and Fraud
In addition to a personal code of ethics, many organizations have a code of business (or pharmacy) conduct policy that all employees agree to maintain. This policy spells out the highest standards of ethical behavior and professional conduct. For example, personnel cannot take even one dose of a prescription medication without a legal prescription or medication order, even for something as simple as a headache. Any unauthorized sale, possession, use, or diversion of controlled drugs results in termination of employment.
Pharmacies must also abide by state and federal laws, such as the Red Flags Rule (having software systems that set up red flags when potential identity theft or fraudulent activities occur) and the False Claims Act (which imposes penalties on trying to defraud government programs with made-up claims). These laws are meant to protect customers, staff, and the pharmacy itself from identity theft and fraud. The pharmacy must have in place store policies and agreements in which all employees must agree to avoid any pretense of participation in any fraudulent activity or identity information theft.
Besides regular retail billing issues with customer credit and identity information, pharmacies may be subject to medical identity theft—that is, a person who seeks health care (or retail purchases) using someone else’s name, credit card, or insurance information. An example of medical identity theft would be a person submitting an altered or forged driver’s license for identification. Each healthcare provider is required by federal law to have a policy and a training program in place to help employees spot warning signs or “red flags” to prevent medical identity theft.
Any pharmacy organization that submits claims to a government insurance provider such as Medicare, Medicaid, or Tricare is required by the Department of Health and Human Services to have a training program for all employees on corporate integrity. Any pharmacy organization’s billing practices are subject to an annual independent review of compliance. Compliance is defined as adherence to a required set of standards, regulations, laws, and practices. The Corporate Integrity Agreement is defined as the obligation to report all fraudulent activities under “whistle-blower protection.” Such activities may occur in the purchasing of pharmaceuticals or the insurance billing and reimbursement policies.
In terms of billing in a community pharmacy practice, all prepared submissions for online adjudication must be accurate. In light of that, a pharmacy technician cannot:
enter or dispense a false prescription;
enter an incorrect days’ supply;
backdate an order if a patient’s refill prescription has already expired;
dispense a medication and wait to bill the insurance company until three days later when insurance for the prescription will be approved;
change a 30-days’ supply order to a 90-days’ supply order without documented approval from the medical office (in most states);
dispense an ordered days’ supply of medication (such as 10 days) and change the days’ supply to five days because the patient’s insurance whistle-blower a five-day supply;
dispense a refill of a drug if the prescription is more than one year old or if a controlled drug prescription is more than six months old;
add a refill and bill insurance if the patient is out of refills without the prescriber’s authorization;
accept a store or drug discount card or a manufacturer’s coupon from a patient who uses a government insurance program—including Medicare Part D;
bill insurance for a brand name drug and dispense a generic drug;
dispense a controlled drug, unless the prescription is written on security paper and is being used for a legitimate medical purpose.
Violations of any of these policies could result in disciplinary action that may include termination. If independent audits demonstrate inaccurate billing, the claim will be denied, and the pharmacy will lose both the cost of the drug and the money required to reimburse the government agency for the amount that was submitted. In addition, the pharmacy may be subject to criminal and/or civil monetary penalties if repeated or flagrant fraudulent activity has occurred.