Programmer Analyzes Allegedly Fraudulent Billing Software

    Programming ExpertThis case involves suspected accounting fraud by a large pharmaceutical company. It was alleged that the company in question was acting in violation of the False Claims Act by billing for mislabeled drugs which were outside of the scope of a government contract. An expert in billing software programming platforms was sought to explain the functionality of the programming in question.

    Question(s) For Expert Witness

    • 1. Please briefly describe your experience with pharmaceutical billing software and its programming.
    • 2. Are you able to discuss the functionality of specific coding? Please explain.

    Expert Witness Response E-076003

    I have 22+ years in the healthcare and pharmaceutical market. I was responsible for all pricing at a pharmacy benefit management company for 17 years. In this capacity, I had to understand claim adjudication functionality on both the pay/retailer and bill/client side of the company’s process. A pure programmer can easily read code but may not be able to interpret the output of the code as it relates to the business objectives and contract requirements. I can read branching logic, as well as address the other aspects of data output to ensure business objectives and contracts requirements are being met. In all claims adjudication, the programming needs to meet NCPDP and HIPPA standards, which I am familiar with.

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