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Old 02-26-2011, 09:35 AM
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mrsD mrsD is offline
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Join Date: Aug 2006
Location: Great Lakes
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mrsD mrsD is offline
Wisest Elder Ever
mrsD's Avatar
 
Join Date: Aug 2006
Location: Great Lakes
Posts: 33,508
15 yr Member
Lightbulb

The insurance companies rely on their customers to alert them to potential fraud issues. If no one ever spoke up, stealing would be more rampant than it is already.

It should not affect you at all.

What may happen is an internal audit of that store. Sometimes the insurance sends in auditors who look at MANY files... so many you wouldn't believe. Any irregularities...and they will cancel payments for up to a year on each infraction(going back a year). Blue Cross does that, and I've seen some HMO's too.
The audit looks at the hard copy of the RX. In the case of RA, it might use the scanned electronic capture. If one is not done, they will pull the original RX.

If you did not get DAW on each RX however, the store just giving you brand because you requested it, the payments may be denied.

I've seen payments denied even on refills, all sorts of minor infractions, in the past.

But I don't think they would do an expensive audit, unless they see other things of suspected sloppiness.
Some insurances send payment bill copies to their customers.
That is how Blue Cross caught an independent pharmacy not far from me several years ago, filling scripts no one picked up. (this was before the "fraud" cases against CVS and Walgreen's.)
Today this is less likely to happen. Customers of Blue Cross got those statements, and realized they never picked up those RXs and reported it. In the end people went to JAIL over it and the store lost its license, etc. It involved hundreds of thousands of dollars of fraudlent billing!

What I did learn once when I reported RX diversion to our state over a decade ago, about a doctor diverting drugs for personal use. When I gave my deposition, involving maybe 50 incidents I reported, they showed me a computer printout they found of the REST.... it was inches thick involving thousands of RXs....
The auditors told me what is found by accident is almost always the tip of a huge mountain of real activity. That situation was a real eye opener for me!

But the bottom line is that chain pharmacies are less likely to be involved in complex fraud, than independents. But it still can happen. A colleague I ran into at a conference, last year told me of a huge internal theft of OxyContin not far from us. It was a big chain and the thieves covered it cleverly. Security did a spot audit on them in person and discovered it, finally. So it can happen. Morphine is a little less common, but brand name may be easier to sell on the black market.

It is your decision in the end, Dej. Living in a small community is not like the big city where I am. So you have to consider more things which may fall out than I would. In my case, whistle blowing is written into our public health code. If another professional does not report, they can be charged if a coverup is suspected...so some responsibility lies on many shoulders in the end.
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Dejibo (02-26-2011), hollym (03-01-2011)