Former Walgreens Clinical Pharmacy Manager Pleads Guilty To $4.4 Million TennCare Fraud Scheme
GREENEVILLE, Tenn. – On Oct. 25, 2016, Amber Reilly, 33, of Jonesborough, Tenn., pleaded guilty to one count of healthcare fraud contained in a federal information, before the Honorable J. Ronnie Greer, U.S. District Judge. Reilly was the former Clinical Pharmacy Manager at the Walgreens Specialty Pharmacy located in the Holston Valley Hospital in Kingsport, Tenn.
Sentencing has been set for Jan. 30, 2017. Reilly faces a potential sentence of up to 10 years in prison, a fine of up to $250,000, and supervised release of up to three years.
In a detailed plea agreement on file with the U.S District Court, Reilly 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 the expensive Hepatitis C drugs of Sovaldi®, Harvoni®, Viekira Pak®, or Daklinza®. 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 patient’s authentic medical lab reports and drug tests showed that they failed to meet TennCare eligibility requirements. However, Reilly admitted to replacing disqualifying information regarding levels of liver scarring and illicit substance abuse on the authentic records with qualifying information, and then submitting the altered records to TennCare. She also admitted to fabricating 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, TennCare paid at least $4,400,000 to purchase Sovaldi®, Harvoni®, Viekira Pak®, and Daklinza® prescriptions for these 51 patients, which they would not have paid if true and accurate prior authorizations, drug test results, and medical lab reports pertaining to these patients had been submitted.
The investigation, which led to Reilly’s guilty plea, 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.