Twelve Indicted in More than $100 Million Health Care Fraud

January 3rd 2017
Lauren Santye, Assistant Editor
Lauren Santye, Assistant Editor

In a kickback scheme involving a sham medical study, Texas pharmacists and physicians cheated Tricare out of millions.

Twelve physicians, pharmacy owners, and marketing experts have been accused of the involvement in an alleged sham medical study that was used to withhold up to $102 million from Tricare, according toUSA Today.

Tricare is the federal health insurance program for active-duty and retired military and their families. According to federal prosecutors, the scheme involved prescribing compounded drugs such as pain, scar, and migraine creams to military families covered by Tricare.

The indictments were centered on a Dallas-based company called CMGRX LLC or Compound Marketing Group. According toUSA Today, the marketing group arranged kickbacks to physicians who prescribed drugs, as well as insured patients who purchased drugs from 4 compounding pharmacies.

Allegedly, the 47-year-old Physician Walter Neil Simmons of Gilbert, Arizona, partnered with 2 other market group representatives to create the fake medical study called the Patient Safety Initiative (PSI). Tricare participants were paid study “grants” of $250 per month for each prescription obtained from a partner pharmacy.

“The defendants and their co-conspirators falsely represented that the study was approved by Tricare and that it was designed to evaluate the safety and efficacy of compounded drugs,” according to the indictment, as reported byUSA Today. “In reality, the PSI study was not approved by Tricare, was not overseen by a qualified physician, epidemiologist, or other medical professional(s), had no control group, and was not designed to gather any useful scientific data relating to the safety or efficacy or any drug.”

Additionally, the indictment alleged that Simmons recruited William F. Elder-Quintana, an El Paso-based physician, who wrote thousands of prescriptions through June 2016 that cost Tricare $96 million. CMGRX employees would reach out to Express Scripts to find out whether certain drugs were covered by Tricare, and would then adjust the prescriptions to maximize payments from Tricare, according toUSA Today.

The indictment accused CMGRX employees of sending prefilled prescription forms to Elder-Quintana, who would then sign the prescriptions after a cursory phone interview with the patient. At other times, the employees would use a stamp donned with Elder-Quintana’s signature to order prescriptions,USA Todayreported.

Among the 12 defendants are Richard Robert Cesario and John Paul Cooper, co-owners and co-operators of CMGRX, who were charged in February 2016.

In October, Simmons was indicted in the US District Court in Dallas on 1 count of conspiracy to commit health care fraud. The charges carry a maximum sentence of 10 years in prison and a $250,000 fine, according toUSA Today.

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