Recent New York Medicaid Settlement with Pharmacy Shows Importance of Checking Excluded Provider List Prior to Filling Prescriptions

02 June 2016 Health Care Law Today Blog
Authors: Jeffrey C. Thrope

A New York pharmacy has agreed to pay approximately $500,000 to the State of New York for improperly billing New York Medicaid for prescriptions written by a physician who had been excluded from the Medicaid program. This settlement serves as an important reminder to all pharmacies operating in New York: Before filling a prescription, pharmacies are required, under New York Medicaid billing rules, to first determine whether the prescriber’s services are eligible for reimbursement. If a pharmacy fills and delivers a prescription written by an excluded provider, those prescriptions are not eligible for Medicaid reimbursement, and should not be submitted by the pharmacy.

Although it may seem burdensome to require a pharmacy to check each and every provider it submits a prescription for, the New York Office of the Medicaid Inspector General expects pharmacies to have a system in place through their compliance efforts, which is reasonably designed to prevent the submission of prescriptions from excluded providers. This means that pharmacies must check the excluded provider list for each provider who writes a prescription prior to filling that prescription.

In addition, if a prescription is written by an excluded provider, and is presented through the New York Medicaid online claiming system, it will not be approved. Most pharmacies will input the information, and the pharmacist will get a red or green light. Pharmacies should not fill the prescription if a red light appears, indicating that the prescriber has been excluded.

The recent settlement serves as a warning to all pharmacies operating in New York.  Attorney General Eric Schneiderman has made it a priority to continue working to prevent Medicaid fraud and recover unlawfully claimed funds, and one such avenue to accomplish this is through pharmacy billing.

This blog is made available by Foley & Lardner LLP (“Foley” or “the Firm”) for informational purposes only. It is not meant to convey the Firm’s legal position on behalf of any client, nor is it intended to convey specific legal advice. Any opinions expressed in this article do not necessarily reflect the views of Foley & Lardner LLP, its partners, or its clients. Accordingly, do not act upon this information without seeking counsel from a licensed attorney. This blog is not intended to create, and receipt of it does not constitute, an attorney-client relationship. Communicating with Foley through this website by email, blog post, or otherwise, does not create an attorney-client relationship for any legal matter. Therefore, any communication or material you transmit to Foley through this blog, whether by email, blog post or any other manner, will not be treated as confidential or proprietary. The information on this blog is published “AS IS” and is not guaranteed to be complete, accurate, and or up-to-date. Foley makes no representations or warranties of any kind, express or implied, as to the operation or content of the site. Foley expressly disclaims all other guarantees, warranties, conditions and representations of any kind, either express or implied, whether arising under any statute, law, commercial use or otherwise, including implied warranties of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Foley or any of its partners, officers, employees, agents or affiliates be liable, directly or indirectly, under any theory of law (contract, tort, negligence or otherwise), to you or anyone else, for any claims, losses or damages, direct, indirect special, incidental, punitive or consequential, resulting from or occasioned by the creation, use of or reliance on this site (including information and other content) or any third party websites or the information, resources or material accessed through any such websites. In some jurisdictions, the contents of this blog may be considered Attorney Advertising. If applicable, please note that prior results do not guarantee a similar outcome. Photographs are for dramatization purposes only and may include models. Likenesses do not necessarily imply current client, partnership or employee status.

Related Services