Federal Government: Why Do You Continue to Do Business With Known Criminals?


Medicare Advantage Fraud by Major Providers
graphic courtesy of The New York Times

To Congress, the Department of Defense, and Federal Government Contract Decision Makers:

Today marks the first day 15,000 community pharmacies across the U.S. can no longer serve active duty and retired military covered by TRICARE. It’s a drastic cut orchestrated by Cigna-owned Express Scripts in the name of “cost savings” but aimed at 15,000 independent pharmacies — tax-paying small businesses mostly located in rural communities miles from the nearest city — and the thousands of TRICARE enrollees those pharmacies serve.

Express Scripts, whose own pharmacies compete with the 15,000 cut pharmacies, wasted no time ushering the dropped patients over to its mail order pharmacy. This is the same Express Scripts whose mail order “refill pill mill” system is at the center of a False Claims lawsuit — the one in which Express Scripts is alleged to have overcharged you, the Federal Government via TRICARE, and us, the taxpayers, billions of dollars in unnecessary prescription refills and dispensing fees for 9 years.

Coincidentally (or maybe not), Express Scripts is owned by Cigna Corp, the subject of a lawsuit filed last week by the U.S. Department of Justice alleging Cigna overcharged Medicare by tens of millions of dollars for false diagnoses between 2012 and 2019 — another 7 years of fraud. Cigna is one of 10 insurers found by a recent New York Times investigation to have routinely engaged in bilking Medicare through “Medicare Advantage” plans.

Yet Cigna and Express Scripts are hardly alone in their criminal exploitation of government-sponsored health care.

This summer, after years of suspicion, CVS Health was named in a whistleblower lawsuit alleging — plausibly — that CVS conspired with its retail CVS pharmacies, its PBM CVS Caremark, and SilverScript, its Medicare-D plan, to drive up drug prices while blocking seniors’ access to frequently prescribed, less expensive generic medications in exchange for substantial drug rebates from manufacturers.

Since 2000, CVS and its subsidiaries (not including Aetna) have racked up 467 major violations, paying out nearly $1.6 billion in penalties. Not that CVS cares what any of us think — patients literally harmed by CVS’ prescription coverage decisions who’ve publicly complained are now designated as “brand terrorists”.

UnitedHealth Group holds more than a quarter of the U.S. Medicare Advantage market, and along with 4 other major Medicare Advantage plan providers (Aetna — owned by CVS! Do we sense a pattern?- Humana, Cigna and Health Net) stands accused of “knowingly (obtaining) inflated risk adjustment payments based on untruthful and inaccurate information about the health status of beneficiaries”. At the heart of these allegations is patient data mining (“upcoding”) in search of real or imagined serious health conditions that would allow UnitedHealth and its crony competitors ample opportunity to overbill CMS.

UnitedHealth’s poor track record is an open secret, and taxpayers are fortunate that SCOTUS refused to hear the case last June, dealing a blow to UnitedHealth’s plan to challenge CMS while continuing to exploit its Medicare Advantage overpayment rule.

Medicare overbillings are now estimated to exceed the annual budgets of NASA, the Children’s Health Insurance Program (CHIP), and U.S. Customs and Border Protection. Meanwhile, CMS is poised to enact an 8.5% Medicare and Medicare Advantage rate hike without having addressed the upcoding issues and the very structure that allows these bad actors to continue helping themselves to billions of dollars at taxpayers’ expense. Still, expect rates to go higher — UnitedHealth and CVS Aetna are among the major Medicare Advantage plan providers whose plans lost star ratings, and the 5% financial bonus CMS awards plans with 4 or more quality stars.

Billing for non-existent diagnoses, arranging formularies for maximum drug maker rebates, colluding with internal divisions to exploit loopholes intended to cover catastrophic health conditions — these actions can be summed up in a single word: fraud.

Fraud is a crime, and those who commit crimes are criminals.

According to RICO statutes, recurring offenses such as fraud constitute a ‘pattern of racketeering activity’ (at least 2 acts committed within 10 years of each other with the same or similar purposes, results, participants, victims, or methods of commission, that are not isolated events). Are these corporations so large that the government is now above enforcing laws that are on the book for the sole purpose of protecting our citizens, employers, and taxpayers?

So we ask you, members of the Federal Government entrusted with stewardship of our billions in tax dollars, why do you continue to do business with known criminals?



Pharmacists United for Truth & Transparency

PUTT is a nonprofit organization dedicated to advocating on behalf of independent pharmacy & fighting against PBM anti-competitive business tactics. TruthRx.org