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Fraud With Insurance Company Prescription Medications

I just recently was denied authorization for Percocet by the insurance company after paying for it for months. I didn't have the money at the time to pay for the medication out of pocket and ended up in an Emergency Room with withdrawal symptoms. The following day I received my workers comp check and immediately went to my pharmacy and paid for the prescription in the hopes to stop the withdrawal. Well the same medication that was authorized in the prior months the billing showed an invoice for $384.00, this was a total shock for I only paid $90.65 for it out of pocket.

So why is the insurance billing provider charging $384.00 when a
patient who pays out of pocket $90.65. The invoice bill shows the
"provider" (pharmacy) as StoneRiver Pharmacy Solutions in Memphis
TN. The funny part is I live in the Bronx and use the same local pharmacy. Why would the invoice say "Memphis, TN."? It gets better the invoice doesn't come from StoneRiver but a company called Healthsystems, L.L.C. located in Tampa Florida, which in turn sends it to Travelers the Claims Adminstrator located in Middleboro, Mass.

I'm not a lawyer, but this set off alarm bells instantly! First thing that came to mind was possible Federal Mail and Wire Fraud or the False Claims Act. No where on these invoices did it show the name and address of the pharmacy where I filled the prescription, only a trail from TN, to Florida, and then to Mass!

Then the truth became clear when I posted this story to a Legal Advise Forum and received a unbelieveable response. A story that explained everything. The title of that story speaks volumes.

"Workers’ Compensation Billing Company to Pay $1 Million for Allegedly Overcharging State Entities for Prescription Drug Coverage - AG’s Office Has Recovered More Than $9 Million to Date Through Workers’ Compensation False Claims Act Investigations"

Can you guess the name of the company involved, yes StoneRiver Pharmacy Solutions!!!!! What makes this even more outrageous the Mass. article states, "The settlement with StoneRiver is the eighth of its kind." Yes you read that right, the 8th settlement!!!!! Well now it appears the companies profits are so large it's easier to settle then change it's fraudulent ways!

Is there any of you out there presently getting invoices that were authorized by the claims adjuster with outrageous billings for your medications? If yes, please post and give details, these insurance companies and their billing partners are inflating the highest and it's hurting everyone espeically us injuried workers of compensation. This has to be addressed. if I can pay $90.65 cash what is the price this
StoneRiver has 60,000 pharmacies under contract, they are lucky if the medication cost them
$30.00, why are these thieves allowed to bill for $384.00? This is one of the reason these insurance companies and their partners are making
billions of dollars off the backs of injuried workers!

Here's the link to the whole story of StoneRiver Pharmacy Solutions, you wouldn't believe what's been gong on!

I am from California, so this crap occurs all the time with medical provider fraud in our workers compensation system, especially in Southern CA.. They/IC should think about copying injured workers on all bills. That may stop this stuff from happening.

I would talk to your attorney about giving your information to the insurance company to investigate.

I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.

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