CVS settles Medicaid coordination of benefits allegations for $17.5 million

by Ben Vernia | April 15th, 2011

On April 15, the Department of Justice announced that CVS Pharmacy, Inc., agreed to pay $17.5 million to settle allegations that it overcharged Medicaid programs in several states for prescription drugs provided to patients who also had third-party insurance. According to DOJ’s press release:

CVS Pharmacy Inc., the retail pharmacy division of CVS Caremark Corporation that operates more than 7,000 retail pharmacies in 41 states and the District of Columbia, has agreed to pay the United States and 10 states $17.5 million to resolve False Claims Act allegations, the Justice Department announced today.

The settlement resolves allegations that CVS submitted inflated prescription claims to the government by billing the Medicaid programs in Alabama, California, Florida, Indiana, Massachusetts, Michigan, Minnesota, New Hampshire, Nevada and Rhode Island for more than what CVS was owed for prescription drugs dispensed to Medicaid beneficiaries who were also eligible for benefits under a primary third party insurance plan (excluding Medicare as the primary payor). The United States alleged that rather than billing the government for what the insured would have been obligated to pay had the claims been submitted solely to the third party insurer (typically the co-pay), CVS billed and was paid a higher amount by Medicaid.

Under the terms of the agreement with the United States and the 10 states, CVS will pay the United States $7,993,615.55 and the states $9,506,384.45 plus interest. CVS has also executed an amendment to a Corporate Integrity Agreement (CIA) with the Department of Human Services, Office of Inspector General (HHS-OIG), that was executed on March 14, 2008, in connection with a separate investigation and settlement. The amendment to the CIA, which will be in effect for three years, will monitor CVS’s implementation of correct billing procedures and the training and education of employees. In addition, an independent review organization will conduct regular audits and issue reports on CVS’s compliance with the terms of the amendment to the CIA.

The case was brought by a CVS pharmacist in St. Paul, Minnesota, who will receive a total of nearly $2.6 million in the case (a 16% federal share, and a 13.8% state share).

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