DJ Drugs & Surgicals Inc. Agrees to Pay $115,000 to Resolve Allegations of Prior Authorization Fraud

BOSTON – A New York-based specialty pharmacy, DJ Drugs & Surgicals Inc., has agreed to resolve allegations that it altered patient medical records and submitted the altered medical records to Medicare in support of prior authorization requests. DJ Drugs will pay $115,000 to settle this matter.

According to the settlement agreement, DJ Drugs processes and fills prescriptions for proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors, an expensive class of cholesterol-lowering medication. Between June 2017 and October 2018, DJ Drugs often completed and submitted prior authorization requests to insurers in order to obtain insurance coverage for PCSK9 prescriptions. As part of this settlement, DJ Drugs agreed to a series of factual admissions, including that, on at least 28 occasions and without express authorization from the prescribing physician, it removed certain information in supporting documentation (e.g., laboratory results, patient medical records) associated with PCSK9 prior authorization requests. DJ Drugs also admitted that it then submitted the altered documents to Medicare plan sponsors for approval.

United States Attorney Rachael S. Rollins; Phillip M. Coyne, Special Agent in Charge of the U.S. Department of Health and Human Services, Office of Inspector General; and Joseph R. Bonavolonta, Special Agent in Charge of the Federal Bureau of Investigation, Boston Division made the announcement. Assistant U.S. Attorney Charles B. Weinograd of Rollins’ Affirmative Civil Enforcement Unit handled the matter.