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False Claims Actions May Rise Under Medicare Part D

Medicare Part D Fraud May Be Brought Under The False Claims Act

A recently unsealed action brought under the False Claims Act is one of the first to allege claims related to Medicare Part D.  Medicare contracts with private entities known as Part D sponsors to administer prescription drug plans.  A sponsor may use subcontractors to obtain and provide the medications.  Medicare  makes certain monthly payments based on a complex set of estimates to the plan sponsor. In the following year, there is a reconciliation of the amounts paid against what the sponsor bid in order to provide benefits.

Government's Take on False Claims Action Under Part D

Of particular interest are the positions taken by the United States  in a Statement of Interest it filed even though the government had chosen not to intervene in the case.  In its filing,  the government plainly stated that the failure to intervene could not be considered to mean the government thought the case lacked merit.  It went on to explain its position that the Prescription Drug Extract records ("PDEs")  used by a Part D plan sponsor to notify Medicare that a drug had been dispensed to a Part D plan participant and the actual cost of that drug are claims under the False Claims Act.  In doing so, it relied on the definition of claim in the False Claims Act and it also relied on the regulations governing the submission of PDEs.  The Government agreed with the relator that the PDE causes the making of payments under Part D.

Conclusion: Prescription Drug Extract Could Be Filed Under False Claims Act

It will be interesting to see if the court will agree with the government's position. If the court does not agree, and finds that the PDEs are not claims, it may be difficult to use the False Claims Act to recover money improperly paid under Medicare Part D.

Contact Us To Learn More

If you have discovered evidence of government fraud, contact an experienced False Claims Act attorney before blowing the whistle. You may be entitled to a substantial reward and the legal protections afforded to whistleblowers under state and federal laws. The attorneys of Berger & Montague are nationally recognized experts in Whistleblower/Qui Tam actions with over a decade of experience pursuing these complex fraud cases. For more information or to schedule your confidential consultation, use the form on this page or call us at 1-800-424-6690.

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For further reading:
Read Futher about Pharmaceutical, Healthcare and Medical Device Fraud
Whistleblower Anti Kickback Medicare Part B Fraud Under the Federal False Claims Act
Why be a Whistleblower?
Federal And State Whistleblower Laws
Whistleblower & False Claims Act Blog at


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