Mentioning health care costs is a sure-fire way to set someone on a rant, and prescription drug prices consistently rank among the most common frustrations for patients and families.
In recent polling by KFF examining the prior year, nearly one in four adults reported taking an over-the-counter medication instead of a prescribed drug due to cost concerns. One in five said they did not fill a prescription because of the expense. Approximately one in seven adults reported cutting pills in half or skipping doses to manage prescription drug costs.
Why have prescription drug prices become so high?
The explanations are complex. The health care system includes numerous entities, many of which were initially formed with the goal of reducing costs or improving efficiency. However, with multiple layers and participants comes increased opportunity for misconduct. Buried within enormous volumes of data, drug pricing fraud can be exceptionally difficult for individuals to identify on their own.
Pharmacy benefit managers (PBMs), for example, were created to lower prescription costs by acting as intermediaries between drug manufacturers and insurers. Yet as PBMs have expanded their role, prescription drug prices have continued to rise. This trend is often attributed to inflation of wholesale prices, extensive lobbying efforts, and drug pricing fraud across the health care industry, according to this article from The Anti-Fraud Coalition.
Whistleblowers with firsthand knowledge of how these organizations operate play a critical role in uncovering drug pricing fraud and other fraudulent conduct.
Reporting suspected fraud can result in the recovery of billions of taxpayer and consumer dollars and helps ensure that federal funds reach the patients and programs they are intended to support.
In fiscal year 2024, the federal government reported $1.67 billion in settlements and judgments arising from health care fraud. This total reflects only cases resolved under the False Claims Act and frequently involves federal programs such as Medicare, Medicaid, and TRICARE.
Federal enforcement agencies depend on whistleblowers to help expose drug pricing fraud and other health care fraud schemes. Individuals who provide original information that leads to a successful enforcement action may be eligible to receive between 10 and 30 percent of the government’s recovery.
If you have witnessed or suspect fraud within the health care industry, it is important to consult an experienced whistleblower attorney before taking action. Keller Grover can evaluate your situation and advise you on the most effective path forward, while protecting your interests and presenting your information appropriately. We offer free and confidential consultations. With more than 30 years of combined experience litigating antitrust, fraud, and employment cases, our attorneys have helped recover billions of dollars for clients.