Aenta's former chief Medicare actuary was placed on administrative leave after filing a whistle-blower lawsuit alleging pharmacy benefits manager CVS Caremark overbilled Medicaid and Medicare for prescription drugs, according to The Columbus Dispatch. Here are four things to know about the lawsuit. 1.
Full Answer
What is the PBM lawsuit against CVS?
An unsealed 2014 lawsuit by an Aetna actuary whistleblower against CVS Caremark, the insurer's pharmacy benefit manager, accuses the PBM of billing the government for prescription drugs at a greater price than it pays to pharmacies. The PBM did not disclose to Aetna how much it was being paid by the pharmacies, ...
How much did Caremark increase in 2012?
In September, 2012, Caremark notified Aetna of an increase in the maximum allowable price of 229 generic drugs. These drugs represented 59 percent of the utilization by Aetna's Part D beneficiaries. On average, the increase was 13 percent for a 30-day supply.
Did Caremark negotiate with Aetna?
In a virtual admission of liability under the Medicare statute and Part D regulations, the lawsuit said, Caremark responded that it had negotiated lower prices on Aetna's behalf but was not required under the contract to provide these prices to Aetna.
When was the whistleblower lawsuit filed?
Behnke’s whistleblower lawsuit, which was filed in 2014, was unsealed on April 4. Behnke was placed on paid leave days later, according to her attorney, Susan Schneider Thomas of Berger & Montague. After the case was unsealed, Thomas said Behnke declined to meet with Aetna attorneys who requested she return and destroy all documents she obtained ...
Does CVS deny Behnke?
An Aetna spokesperson declined to comment. CVS has denied the Behnke's allegations.
How many children were enrolled in Aetna in 2016?
In September 2016, “a staggering 96.6%” of 747 children enrolled with Aetna’s for periodic screening at Crozer-Keystone had not been screened in the prior year. All the while, the insurer was collecting money to care for those children, the suit says.
What is EPSDT in Aetna?
At Aetna, Wessner’s official role was coordinator for the Early Periodic Screening, Diagnostic and Treatment, a benefit known as EPSDT and a Medicaid workhorse. The benefit covers millions of children under 21 years old, mandating screenings and testing for physical, developmental, dental, and mental health. Children diagnosed with ailments or conditions are treated through EPSDT.
Did Aetna take Medicaid money?
Nurse whistleblower says Aetna took Medicaid money and failed to provide care to poor children
Is Aetna available in Pike County?
In Pike County, a rural area southeast of Scranton, all five of the pediatric providers in the Aetna network were not available to low-income kids, the suit claims.
Does Pennsylvania pay Aetna?
Pennsylvania paid Aetna a monthly per member fee in exchange for the insurer providing care for the children through a network of doctors and health facilities. By not providing an adequate provider network, Aetna “decreases the number of medical services it has to cover while still being paid by the government,” the suit says.
Do insurance companies cover Medicaid?
Insurers and providers are expected to cover the medical care for the Medicaid beneficiaries and earn a profit with the per enrollee monthly fees. “There is a built-in incentive to under-service that could lead to lower costs and higher profits,” Somers said.
Is the Department of Human Services aware of the whistleblower suit?
A spokesperson for the Department of Human Services said on Tuesday that the state agency was aware of the whistleblower suit and that its teams “actively monitor beneficiary, stakeholder and provider complaints and concerns to identify potential problems with [provider networks] and take appropriate action.”