Former Clinical Pharmacy Manager Sentenced to Serve 16 Months in Prison for $4.4 Million TennCare Fraud Scheme
GREENEVILLE, Tenn. – On June 26, 2017, Amber Reilly, 33, of Jonesborough, Tennessee, was sentenced by the Honorable J. Ronnie Greer, U.S. District Judge, to serve 16 months in federal prison for healthcare fraud, which resulted in at least a $4.4 million loss to TennCare. Upon her release from prison, she will be supervised by U.S. Probation for three years.
Reilly, a former clinical pharmacy manager, pleaded guilty in October 2016 to one count of healthcare fraud. In her plea agreement, she admitted that between October 2014 and April 2016 she falsified prior authorizations, medical lab reports, and drug test results for at least 51 Hepatitis C patients who had prescriptions for expensive drugs used to treat Hepatitis C. These patients had health insurance through TennCare, which does not pay for Hepatitis C prescriptions for patients who abuse illicit substances or who have limited or no scarring of the liver. The patients’ authentic medical lab reports and drug tests showed that they failed to meet TennCare eligibility requirements. However, Reilly replaced disqualifying information regarding levels of liver scarring and illicit substance abuse on the authentic records with qualifying information, and then submitted the altered records to TennCare. She also fabricated allergies on the prior authorization forms of some of these patients so they could receive the most expensive Hepatitis C drug, Harvoni®.
As a result of Reilly’s conduct, at least $4.4 million was paid by TennCare to purchase prescriptions for these 51 patients, which would not have been paid if true and accurate prior authorizations, drug test results, and medical lab reports pertaining to these patients had been submitted.
This investigation was conducted by the Tennessee Bureau of Investigation and Department of Health and Human Services – Office of the Inspector General. Assistant U.S. Attorney T.J. Harker represented the United States.