Insurance Commissioner Dave Jones today filed an insurance-fraud complaint in Alameda County Superior Court on behalf of the State of California against AbbVieInc. alleging AbbVie gave illegal kickbacks to health care providers to prescribe humira—an expensive and dangerous drug with potentially deadly side effects. The case, which is filed on behalf of the State under the Insurance Frauds Prevention Act, alleges that private insurers have paid out $1.2 billion in humira-related pharmacy claims, making this the largest health insurance fraud case in department history.
According to the complaint, AbbVie engaged in a far-reaching scheme including both classic kickbacks—cash, meals, drinks, gifts, trips, and patient referrals—and more sophisticated ones—free and valuable professional goods and services to physicians to induce and reward humira prescriptions. These professional goods and services included free insurance processing and prior authorizations, gifts of medical practice management hardware and software, and even marketing assistance, all of which save physicians valuable staff time and resources.
“AbbVie spent millions convincing patients and health care professionals that AbbVie Ambassadors were patient advocates—in fact, the Ambassadors were humira advocates hired to do one thing, keep patients on a dangerous drug at any cost,” said Insurance Commissioner Dave Jones. “Pharmaceutical companies know financial inducements are illegal, and patients depend on their health care professionals for straight forward honest information about their care and medication risks. In this case, patient care was traded for $1.2 billion in ill-gotten gains.”
The key to AbbVie’s success in pulling off its scheme, and among the most troubling aspects of it, is the fact that AbbVie inserts its own personnel directly into the homes of patients. When doctors prescribe humira, AbbVie sends its registered nurses—which AbbVie calls “Ambassadors”—into patients’ homes, representing them to be an extension of the doctor’s office.
The system AbbVie established takes advantage of the Ambassadors’ nursing background and direct access to patients to serve the biopharma giant’s financial interest in getting patients to take humira by downplaying its risks. Ambassadors are trained to send patient complaints directly to AbbVie and not the patients’ treating physicians. Ambassadors also provide unbalanced information, as they are trained to tout the drug while at the same time also instructed on methods to avoid directly answering patient questions about risks of the medication, including those pertaining to humira’s serious and important side effects.
At no cost and considerable gain to the physician’s office, AbbVie nurses provide pharmacy and insurance authorization assistance, open enrollment resources, paperwork help, advice on insurance products, and other services, all of which provide a substantial value and save physicians’ time, money, and resources. The catch is AbbVie only provides the Ambassadors as long as the physicians continue to prescribe AbbVie’s drug instead of selecting another course of treatment.
The allegations of AbbVie’s misconduct were brought to the attention of the department by a whistleblower. The whistleblower, referred to legally as a relator, is a registered nurse and was employed as an AbbVie Nurse Ambassador in Florida. The relator continues to be a party to this action and is represented by Rachel Geman, Robert Nelson, and Jason Lichtman of the law firm of Lieff Cabraser Heimann & Bernstein, LLP.