In a major case of Tricare billing fraud, a Florida Federal judge has sentenced a pharmacy owner and his assistant to 17 years and 15 years in prison respectively.

According to the qui tam lawsuit, these men created a scheme centered on Tricare billing fraud that cost the federal government over $30 million in billings claims for unnecessary prescriptions.

Defendants Serge Francois and his “right hand man” Patrick Tonge received these prison sentences from United States District Judge Darrin P. Gayles for their alleged Tricare billing fraud scheme. Francois reportedly received 204 months in prison along with three years probation, while Tonge got 188 months in prison and three years probation. Judge Gayles also ordered them to pay $31,259,252 in restitution to resolve the Tricare billing fraud scheme.

Francois owned and operated the Atlantic Pharmacy and Compounding, with Tonge as his second in command in running their alleged Tricare billing fraud scheme.

Tonge and Francois allegedly conspired to pay significant financial kickbacks to markets who paid doctors to write prescriptions for expensive and unnecessary medications. These medications were reportedly compounded directly in Atlantic Pharmacy, with each bottle priced up to $17,000.

Doctors who were involved in the Tricare billing fraud reportedly filled prescriptions based on patient notes and did not actually meet the patients. Pharmacists would then set the prescriptions to automatically refill, which were sent without copayments to patients who did not need or request the drugs.

Tricare ceased paying for these claims in May 2016 after news of the billing frauds with other pharmacies came out. Approximately 17 people have either pled guilty or have been convicted for being involved in the alleged Tricare billing fraud.

Overview of Tricare Healthcare Fraud

The United States Department of Justice noted this was the largest healthcare False Claims Act (FCA) case involving the federal Tricare healthcare program to go to trial. Tricare is a federal healthcare program designated for United States military services members, including active duty and retired members.

Tricare is managed by the Defense Health Agency, under the leadership of the Assistant Secretary of Defense. According to their mission statement, Tricare strives to provide top tier healthcare to military members and their families.

Given the fact that the Tricare billing fraud scheme severely impacted numerous United States military members, this healthcare fraud is considered especially heinous.

“The fraud committed in this case was particularly egregious, as it targeted the health care program for the men and women in uniform who protect this country. [T]he jury’s verdict exemplifies this office’s tireless commitment to prosecuting health care providers and individuals who commit fraud against the Tricare program and any federal health care program,” said one of the attorneys involved in the lawsuit.

According to the qui tam lawsuit, Francois and Tonge were found guilty of multiple counts of healthcare fraud, conspiracy, kicking back money to partners in their scheme, and other similar offenses. Francois was also found guilty of making false statements regarding drug misbranding when sending bills to Tricare.

In addition to Tricare, the Federal Employee Health Benefit Program was also targeted in the billing scheme. Both healthcare programs had been billed over $37 million, with Tricare paying over $30 million in false claims.

This Tricare Billing Fraud Lawsuit is U.S. v. Simsir et al., Case No. 1:16-cr-20399, in the U.S. District Court for the Southern District of Florida.