Solera Specialty Pharmacy: The Prescriber’s Name, the Pharmacy’s Answers

Solera Specialty Pharmacy and its chief executive agreed to pay $1.31 million to resolve allegations of false Medicare claims for Evzio involving false prior authorizations and copay waivers. In its criminal deferred prosecution agreement and civil settlement, Solera admitted that its staff sometimes signed without the physician’s authorization and submitted false clinical information to secure coverage.

The Department of Justice’s July 13, 2022 announcement described those admissions. The Pompano Beach, Florida pharmacy dispensed Evzio from January 2017 through May 2018. Used to rapidly reverse opioid overdoses, Evzio was the highest-priced version of naloxone on the market during that period. Insurers frequently required prior authorization before approving coverage.

That put the authorization form directly between the pharmacy and payment for an expensive drug.

How Solera Represented the Prescriber

Under the criminal and civil agreements, Solera admitted completing Evzio prior-authorization forms in place of the prescribing physicians. Its admissions included instances in which staff signed without the physician’s authorization and listed Solera’s contact information as though it belonged to the physician.

Putting the pharmacy’s information in the physician’s place made the business seeking payment appear to speak for the prescriber. The insurer was being given a clinical request whose apparent source concealed who had prepared it.

We expect the prescriber’s name on a clinical request to mean something. Here, the pharmacy supplied the answers and sometimes signed without permission, then put itself where the insurer would look for the physician’s contact information. The form borrowed the doctor’s authority while directing questions back to the business seeking payment.

The Clinical Answers Behind Evzio Coverage

Solera also admitted in those agreements that it submitted false clinical information to secure approval for Evzio. The pharmacy sold the product, and insurers frequently wanted a reason to cover that particular version of naloxone. The business seeking the payment was writing the reason it should be paid.

Medicare and the taxpayers funding it bore the cost of the alleged false claims. A drug meant to reverse an overdose became the product behind a payment request built on false clinical answers.

For this kind of case, we compare the clinical support received from the prescriber with the answers submitted to the payer. The same question underlies pharmacy diagnosis certifications: does the coverage statement match the supporting records? In Solera’s case, the admitted false information accompanied requests that the pharmacy had completed in physicians’ place.

Medicare Copay Waivers Without a Hardship Assessment

Solera’s admissions in the criminal and civil agreements also covered numerous Medicare copay waivers for Evzio without analyzing whether the patient had a genuine financial hardship.

The patient amount on the claim, the payment record and the reason for a waiver matter together here. We examine them against the pharmacy’s actual decisions about collecting copays. That connects the admitted practice to the patient balance instead of stopping at the authorization form.

The person handling patient balances may know how a waiver decision was made even if someone else prepared the prior authorization. Bringing those accounts together connects the request for coverage with the handling of the patient’s bill. It also identifies whose instructions governed each part of the work.

Solera Pharmacy Evzio Settlement Case and Independent Review

The civil settlement covered Solera and its chief executive. The criminal deferred prosecution agreement concerned the pharmacy and a criminal information charging health care fraud. The Justice Department reported Solera’s operational admissions under both agreements.

Solera and its chief executive also entered a three-year integrity agreement with the Department of Health and Human Services Office of Inspector General. The Justice Department described measures aimed at compliant prior authorizations and collection of beneficiary copays, together with reviews by an independent review organization.

Those checks reached the same work that produced the claims: the information submitted for approval and the handling of the patient’s payment obligation. The agreement put independent review around both practices.

From the Authorization to the Paid Claim

We connect the submitted authorization with the payer’s decision and the resulting payment. The prescriber’s supporting information gives us the comparison for the clinical answers; the payment history shows which request reached a government claim. If that history includes product-code changes during rebilling, we examine whether the billed product still matches the approved request.

A completed form shows the answer sent to the insurer. The employee who handled it may know why that answer appeared and whose instruction put it there. That is where experience inside a healthcare business gives the paperwork meaning, and where we work with the insider to connect the decision to the money.

The Manufacturer and Other Evzio Pharmacies

The manufacturer, kaléo, agreed to a separate $12.7 million settlement in 2021, compared with the $1.31 million civil settlement by Solera and its chief executive. The government’s manufacturer-side allegations included directing prescriptions to preferred pharmacies. That puts the referral handoff beside the pharmacy’s later work obtaining authorization.

The separate Benzer pharmacy resolution supplies another example of the authorization pattern. In their civil agreement, Benzer Pharmacy Holding, Berkley Pharmacy and RX Care Four admitted unauthorized signatures, substituted fax details and false treatment-history or clinical assertions.

The recurring question is who supplied the information that persuaded the insurer to pay. These cases reach across the manufacturer-to-pharmacy relationship: the referral can explain how a prescription arrived, while the authorization shows what the pharmacy said to get it covered.

A Manufacturer Employee Brought the Whistleblower Case

A former kaléo employee brought the qui tam claims included in Solera’s civil settlement. The Justice Department announced that the whistleblower would receive a share of the settlement amount. The separate manufacturer settlement carried a $2.5 million whistleblower award. An employee’s view from inside the manufacturer mattered beyond that company’s own payment.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

Your Knowledge Behind the Authorization

If you handled Evzio requests, copay decisions or the handoff from a manufacturer to a pharmacy, speak to one of our Whistleblower Experts about how those approvals were won. We build your strongest pharmacy whistleblower case with you around who supplied the answers, who directed the work and which government claims followed, bringing in pharmacy fraud whistleblower lawyers who understand authorization disputes. Throughout the case, you have our expertise on your side of the table.