Source: United States Department of Justice Criminal Division
Ahold Delhaize USA Inc. (Ahold Delhaize), headquartered in Quincy, Massachusetts, has agreed to pay the United States and participating states a total of $40 million to resolve allegations that it violated the False Claims Act and state analogs by reporting inflated “usual and customary” prices on claims to federal healthcare programs.
“Federal healthcare programs rely on pharmacies reporting accurate pricing information used in the applicable payment formulas,” said Assistant Attorney General Brett A. Shumate of the Justice Department’s Civil Division. “If pharmacies report inflated ‘usual and customary’ prices on claims to federal healthcare programs, the programs pay more than they should on those claims.”
“Pharmacies are trusted with charging the contracted prescription prices to Medicare and Medicaid and not unfairly and unlawfully taking advantage of the government and the public,” said U.S. Attorney Troy Rivetti for the Western District of Pennsylvania. “This settlement confirms that the United States will take all necessary steps to bring to justice dishonest pharmacies.”
“Pharmacies in federal health care programs must report truthful prices. Inflating those prices, as alleged here, puts the integrity of taxpayer‑funded programs at risk,” said Acting Deputy Inspector General for Investigations Scott J. Lampert of the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). “Working closely with our law enforcement partners, HHS‑OIG will continue to aggressively pursue such conduct to protect these critical programs and all the people who rely on them.”
The United States alleged that Ahold Delhaize supermarkets with in-store retail pharmacies – including supermarket chains operating under the names Giant, Hannaford, Stop & Shop, Food Lion, and others – operated prescription savings programs pursuant to which enrolled members received discounted prices on prescription drugs. The United States contends that, in light of the features and operations of those savings programs, and the applicable Medicare Part D, Medicaid, and TRICARE program requirements (including, where applicable, contractual requirements), the discounted prices should have been reported as “usual and customary” prices on claims submitted to Medicare Part D, Medicaid, and TRICARE. Reported “usual and customary” prices serve as ceiling prices on payments to pharmacies under the applicable healthcare program payment formulas. The United States contends that Ahold Delhaize pharmacies failed to accurately report their discounted prices as their “usual and customary” prices on claims to Medicare Part D, Medicaid, and TRICARE, causing those programs to pay inflated amounts on such claims.
The Medicaid Program is jointly funded by the federal government and the states. Of the $40 million resolution announced today, the federal share is $32.9 million and the remainder will be paid to states participating in the settlement.
The civil settlement includes the resolution of claims brought under the qui tam or whistleblower provisions of the False Claims Act by Lawrence LaBenne, who was a pharmacist at an Ahold Delhaize supermarket in Pennsylvania. Under those provisions, a private party can file an action on behalf of the United States and receive a portion of any recovery. Mr. LaBenne will receive $6,083,587 from the federal share of the settlement. The qui tam case is captioned U.S. ex rel. LaBenne v. Koninklijke Ahold Delhaize N.V., et al., Civil Action No. 18-CV-925 (W.D. Pa.).
This settlement was the result of a coordinated effort between the Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, and the U.S. Attorney’s Office for the Western District of Pennsylvania, with assistance from the Department of Health and Human Services, the Defense Health Agency, and state Medicaid programs.
The investigation and resolution of this matter illustrates the government’s emphasis on combating healthcare fraud. One of the most powerful tools in this effort is the False Claims Act. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).
The matter was handled by Trial Attorney Jeffrey A. Toll and Assistant U.S. Attorney Paul Skirtich for the Western District of Pennsylvania.
The claims resolved by the settlement are allegations only and there has been no determination of liability.