Health-care fraud costs taxpayers billions of dollars every year, with con artists constantly finding new ways to cheat the system. And while federal investigators report they are trying their best to crack down on crime, one scheme involving pharmacies and Medicaid is growing so quickly they said they can’t work fast enough to keep up.
Here’s how the scam works, according to Tom O’Donnell, special agent in charge with the Health and Human Services Office of Inspector General: An owner of a pharmacy asks customers to bring in prescription slips from doctors. But instead of filling the scripts and dispensing the drugs, the owner pays the customers a small fee and then bills Medicaid for the drugs that were never dispensed.
CNBC rode along with the Feds as they busted one pharmacy owner in Brooklyn, Aleksandr Ilyayev. Our cameras were rolling during the entire raid, from the early morning briefing session to the owner’s ultimate arrest. Investigators had been keeping a close eye on the owner for a year, and said they already captured him on undercover video—allegedly pulling off a brazen scheme to rip off taxpayers.
The owner allegedly asked patients to bring prescription slips to his pharmacy in exchange for cash and New York Transit Authority MetroCards. The cash amounts weren’t big—the owner allegedly dished out $20 to $40 for each prescription, according to investigators.
From there, O’Donnell said, the owner would bill Medicaid for drugs that were either partially filled, or never dispensed at all. O’Donnell said he also billed for refills.
According to federal agents, the owner focused on prescriptions for expensive HIV drugs like Atripla, Isentress, Prezista and Reyataz. Pharmacies are reimbursed by Medicaid for these drugs—often paying out as much as $1,500 for a 30-day supply.
All told, investigators allege the owner bilked Medicaid out of almost $1 million. Through his attorney, Ilyayev denies the charges.
This alleged scheme is just the tip of the iceberg, said O’Donnell, with other, similar schemes being played out at mom- and-pop pharmacies all over the country. He added that his department’s caseload has quadrupled in the past five years.
It’s a “drug trade subsidized by taxpayers,” added Gary Cantrell, deputy inspector general in the Office of Investigations.
According to Lauren Mack, executive assistant district attorney in Kings County, Brooklyn, between 3 percent and 10 percent of all Medicaid spending is fraudulent, or $184 million to $630 million worth of fraud.