A 44-year-old individual from Florida, alongside other co-conspirators, owned and managed Synergy Pharmacy. Through this pharmacy, they defrauded Pharmacy Benefits Managers (PBMs). PBMs pay pharmacies for prescription claims on behalf of both public and private health insurance programs. The perpetrators formed a scheme to swindle PBMs into approving thousands of fraudulent prescriptions. These prescriptions were obtained through a two-pronged telemedicine scheme. The first step required them to acquire the patient’s insurance information through the telemedicine platform. Then, they misled doctors to provide the prescriptions by telling them that the patients had requested them. The medicine requested through these prescriptions was hand-picked by Bolos, who always chose the most profitable ones. The co-conspirators had put this scheme in motion in 2015, and for almost three years they issued more than 60,000 fraudulent prescriptions. Insurance companies reimbursed a total of $174 million for these prescriptions, and neither the doctors who issued the prescriptions nor the patients had any idea that this fraud was occurring.
The US government spent years investigating this matter, and the investigation involved many government agencies like the U.S. Department of Health & Human Services, the Food and Drug Administration, the U.S. Postal Service, the Office of Inspector General, the Federal Bureau of Investigation, and more. In the end, the co-conspirators were charged with health care fraud, mail fraud, and felony misbranding of medication, and most of them pled guilty. The 44 year old individual from Florida was sentenced to 14 years in prison, and another co-conspirator named was sentenced to 33 months. As part of their sentences, they were both ordered to pay $24.6 million in restitution.
Do you have a valid claim?
If you witnessed any widespread suspicious activity within your workplace, you might have a chance of becoming a whistleblower by reporting an ongoing fraudulent scheme. However, to increase your chances of success, you must be sure to back up your claim with substantial evidence or privileged information.
A Quick Whistleblower Checklist
Is the fraudulent scheme widespread enough?
Has the fraud been perpetuated for years or involves large sums of money?
Do you possess any physical evidence of the fraud (documents, forged signatures)?
Do you have access to privileged information which may help our investigators?
Do you work as an insider within the company perpetrating the fraud?
Did you witness any ongoing illegal behavior within your workplace?
Have you been forced into taking part in any suspicious corporate activity?
