Legal Question in Insurance Law in Pennsylvania

Re: Perscription Insurance Fraud

You asked 1) if improper to charge an assisted living home resident and the insurer for the cost of medications and 2) whether it was necessary for the home to provide the remainder of prescriptions on discharge.

In the first case the answer is most definitely yes. The nursing home was acting as a pharmacy in that it was responsible for filling the prescriptions and collecting proper payment. If the insurer had a negotiated rate for the prescriptions with the home (as a pharmacy) then the home is bound to accept that rate as the full payment for a prescription. It may not even have a deficit other than a permissable co-payment. In other words, if a prescription is $100 retail and the negotiated isurance rate is $70 with a 10 dollar co-payment then the nursing home may not charge more than $70 less the $10 co-payment, which would be paid by the patient. To do anything else is fraudulent.

In the second case it could be a number of circumstances and the most benign should be the initial assumption. This would be where presciptions are filled on a daily basis and that there simply isn't a procedure in place to allow for providing the remaining amount for the period on discharge. Again, most likely is that prescriptions are filled daily rather than for a fixed period. If the prescriptions are filled for a fixed period then the amount leftover must be either properly disposed of or given to the patient. It is unlawfull to re-use prescriptions medications once prescribed. There is a significant potential for fraud or at least what would be called savings on shrinkage. But the issue must be examined more thoroughly.

I am eager to sleak to the patient about these issues and would appreciate if she would contact me to discuss them.

Regards,

Roger Traversa

Email: [email protected]

Phone: 215.279.8940