Pharmaceutical Representative Admits Role in Health Care Fraud Conspiracy Targeting State Health Benefits Programs
CAMDEN, N.J. – A pharmaceutical representative today admitted his role in a conspiracy to defraud New Jersey state health benefits programs, U.S. Attorney Craig Carpenito announced.
Dan Irvine, 50, of Oceanport, New Jersey, pleaded guilty by video conference before U.S. District Judge Robert B. Kugler to an information charging him with conspiracy to commit health care fraud.
According to documents filed in this case and statements made in court:
Compounded medications are specialty medications mixed by a pharmacist to meet the specific medical needs of an individual patient. Although compounded drugs are not approved by the Food and Drug Administration (FDA), they are properly prescribed when a physician determines that an FDA-approved medication does not meet the health needs of a particular patient, such as if a patient is allergic to a dye or other ingredient.
Between October 2015 and March 2016, Irvine participated in a conspiracy that targeted insurance plans that paid thousands of dollars for certain prescription compound medications – including vitamins and pain creams – from an out-of-state pharmacy, identified in the information as “Compounding Pharmacy.” The conspirators found patients with these insurance plans, particularly New Jersey state and local government and education employees. An entity referred to as the “Pharmacy Benefits Administrator” provided pharmacy benefit management services for the State Health Benefits Program, which covers qualified state and local government employees, retirees, and eligible dependents; the School Employees’ Health Benefits Program, which covers qualified local education employees, retirees, and eligible dependents; and other insurance plans. The Pharmacy Benefits Administrator paid prescription drug claims and then billed the State of New Jersey or the other insurance plans for the amounts paid.
Irvine obtained insurance information from individuals with favorable insurance coverage and filled out prescriptions for compounded medications. Irvine selected medications based on their high insurance reimbursements and selected the maximum quantities and refills to generate the highest insurance reimbursements. Irvine then had doctors sign the prescriptions without the doctors examining the individuals or determining that the individuals had a medical necessity for the compounded medications. Irvine faxed the completed, signed prescriptions to the Compounding Pharmacy. Irvine had an agreement to receive as a commission a portion of the amount paid by the Pharmacy Benefits Administrator for prescriptions he obtained. He received $63,017 in commissions.
Irvine faces a maximum penalty of 10 years in prison and a $250,000 fine, or twice the gain or loss from the offense. As part of his plea agreement, Irvine must forfeit $63,017 in criminal proceeds and pay restitution of at least $208,989. Sentencing is scheduled for Dec. 16, 2020.
U.S. Attorney Carpenito credited agents of the FBI’s Atlantic City Resident Agency, under the direction of Acting Special Agent in Charge Joe Denahan in Newark; IRS – Criminal Investigation, under the direction of Special Agent in Charge Michael Montanez in Newark; and the U.S. Department of Labor, Office of Inspector General, New York Region, under the direction of Special Agent in Charge Michael C. Mikulka, with the investigation leading to the guilty plea. He also thanked the Division of Pensions and Financial Transactions in the State Attorney General’s Office, under the direction of Attorney General Gurbir S. Grewal and Division Chief Aimee Nason, for its assistance in the investigation.
The government is represented by Assistant U.S. Attorneys R. David Walk Jr. and Christina O. Hud of the U.S. Attorney’s Office in Camden.