There is something about third-party pharmacy benefit managers. Put them together with state attorneys general and you have a 100% chance of uncovering overpayments under medical plans for government and private business employees as well as for recipients of Medicare benefits. The pharmacy managers do a lot of managing, from negotiating prices with pharmaceuticals, to deciding on drug coverage, to formulas for reimbursement, and developing relationships with retail pharmacies. With all those layers of managing it becomes difficult to understand who is paying whom how much and how much the third-party manager is getting for its work.
Centene just agreed, without admitting fault or liability, to settle disputes with Ohio and Mississippi for $88 million and $55 million respectively. Despite admitting nothing, Centene indicated that the settlement related to its practices in 2017 and 2018 and those practices have now been halted. We did not do anything wrong, but, just in case, we’ve changed what we are doing. That last line seems to be a part of every settlement at both state and federal levels when it comes to regulatory oversight.
Some follow-up questions:
1. If it was not wrong, was it a gray area?
2. Were you operating in loophole territory?
3. Was there full disclosure to all involved about your practices, procedures, and payments?
4. Did other companies engage in the same practices?
Those four questions would go a long way in preventing the settlements for doing nothing wrong.